Docstoc

GOVERNMENT OF SIERRA LEONE

Document Sample
GOVERNMENT OF SIERRA LEONE Powered By Docstoc
					              REPUBLIC OF SIERRA LEONE




     MINISTRY OF HEALTH AND SANITATION




    REPRODUCTIVE AND CHILD
    HEALTH STRATEGIC PLAN
          2008 - 2010

 A strategic plan to better deliver
  health services for women and
              children



                          January 2008
Note as of 25 January still need to:
    insert percentages for user perception output pages 31 and 39
    Add annex D - costs
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008



Ministry of Health and Sanitation mission statement, values, working
principles, goal and priorities



Mission Statement
To ensure that available resources (human, financial and material) are
maximally utilized for the purpose of achieving the Ministry’s goal, which is to
provide quality, affordable and accessible health care services to the people
of Sierra Leone.


Values*
    Respect for life
    Right to health for all
    Equity
    Enabling work environment


Working principles*
   Confidentiality
   Treating all people with dignity and respect
   Community participation
   Transparency, accountability and efficiency
   Capacity building through learning on-the-job and formal education and
     training
   Affordability and sustainability


Goal
The overall goal of the health sector is to maintain and improve the health of
all Sierra Leoneans resident within the country.’ (2002 National Health Policy)


Priorities*
                Develop and implement a package of essential basic services
                Develop and implement a package of essential hospital services
                Public health interventions
                Laws and regulations
                Human resource development
                Decentralisation
                Health management, institutional development and governance
                Health information, planning, monitoring and evaluation
                Health financing
                Coordination

*2007 draft for the new National Health Policy 2008 - 2015




                                                                                                     2
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008



TABLE OF CONTENTS
LIST OF ABBREVIATIONS

FORWARD

EXECUTIVE SUMMARY
ACKNOWLEDGEMENTS


CHAPTER 1. INTRODUCTION
1.1  What is different and new and what is the key message?
1.2  Strategic plan development process
1.3  Overview of the reproductive and child health strategic plan context


CHAPTER 2. WHERE ARE WE NOW IN REPRODUCTIVE AND CHILD HEALTH?
2.1  Definition of reproductive health and of child health
2.2  Current reproductive and child health policies, plans, acts and other
     documents
2.3  Main issues in, and SWOT of, reproductive and child health
2.4  Key reproductive and child health responsibilities at different levels of the
     health system



CHAPTER 3. WHERE DO WE WANT TO BE, WHAT DIRECTION AND SCOPE OF
              WORK IN REPRODUCTIVE AND CHILD HEALTH?
3.1  Ministry of Health and Sanitation Reproductive Health Policy and Child Health
     Policy: Goal, objectives, outcomes and guiding principles
3.2  Strategic direction for reproductive and child health 2008 – 2010
3.3  The reproductive and child health strategic plan framework 2008 - 2010
3.4  Critical success factors, key implications, risks and assumptions


ANNEXES

        Annex A:          Reproductive and child health strategic plan framework
        Annex B:          Draft outline of content of package of essential basic services
        Annex C:          Public health and clinical interventions in reproductive and
                          child health services
        Annex D:          Summary of cost of reproductive and child health strategic plan
        Annex E           Contents page of the reproductive and child health operations
                          manual


VOLUMES

        Volume I          Reproductive and child health strategic plan costs
        Volume II         Monitoring and evaluation component of the reproductive and
                          child health programme
        Volume III        Reproductive health norms and standards




                                                                                                     3
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008


LIST OF ABBREVIATIONS


AIDS             Acquired immunodeficiency syndrome
ARVs             Anti-retrovirals
ACT              Artemisinin-based combination therapy
BCC              Behaviour change and communication
BEmONC           Basic emergency obstetric and neonatal care
CCM              Country Coordinating Mechanism
CEDAW            Convention on the Elimination of All Forms of
                 Discrimination against Women
CHASL            Christian Health Association of Sierra Leone
CRC              Convention on the Rights of the Child
DACO             Development Assistance Coordination Office
DFID             Department for International Development, UK
DHMT             District health management team
DOTS             Directly observed treatment strategy
FGM/C            Female genital mutilation/cutting
FP               Family planning
GoSL             Government of Sierra Leone
HIES             Household income and expenditure survey
HIPC             Highly indebted poor country
HIV              Human immunodeficiency virus
ICC              Inter-agency Coordination Committee
IEC              Information, education and communication
I-PRSP           Interim poverty reduction strategy programme
ITN              Insecticide treated net
M&E              Monitoring and evaluation
MCHP             Maternal child health post
MDGs             Millennium development goals
MICS             Multi-indicator cluster survey
MoHS             Ministry of Health and Sanitation
MTEF             Medium term expenditure framework
NGO              Non-governmental organisation
NHA              National health accounts
NHPAC            National Health Policy Advisory Committee
NHSSC            National Health Sector Steering Committee
NSCSRCH          National Steering Committee for Sexual, Reproductive and Child
                 Health
PHC              Primary health care
PHU              Peripheral health units
PRSP             Poverty reduction strategy programme
RCH              Reproductive and child health
SLIHLCS          Sierra Leone integrated household living conditions survey
SSL              Statistics Sierra Leone
TB               Tuberculosis
TBA              Traditional birth attendant




                                                                                                     4
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008


REPRODUCTIVE AND CHILD HEALTH STRATEGIC PLAN 2008 - 2010



FOREWORD


As we are all painfully aware, Sierra Leone continues to be ranked as one of the
poorest countries in the world, with the highest child and maternal mortality indices
worldwide. As a new government, we are totally committed to improving this
situation in the shortest time possible. We cannot allow this sad state of affairs to
continue unabated. The time to act is now.

The development of this Reproductive and Child Health Strategic Plan 2008 - 2010 is
therefore very timely and represents a significant milestone in our efforts to improve
the health status of our mothers and children. It was developed in close collaboration
with all stakeholders in the health sector including our major development partners,
and it is also to be implemented in close partnership with them. My Ministry is
committed to supporting the implementation of this important plan. By this I mean
not only supporting politically, but also financially in terms ensuring adequate
government funding of the health sector in general, and the implementation of this
plan in particular. No efforts will be spared to mobilize the resources necessary to
ensure successful implementation, and we hope we can continue to depend on our
donor partners to support the process.

As the situation further stabilizes, we expect the next strategic plan to cover a longer
period that will better fit into the timeline for the achievement of the MDGs, i.e., to
cover the period up to the year 2015. As a government, we are fully cognizant of our
responsibilities as signatories of the millennium development agreement, and remain
committed to do all in our powers to adhere to it. Successful implementation of this
RCH strategic plan therefore is of extreme importance to us as a government. We
owe it to the people of this country to improve their health and socio-economic well-
being. We will ensure that the goals and objectives of this plan are met as a first step
towards achieving this overall goal.




DR SOCCOH KABIA
HONOURABLE MINISTER OF HEALTH
FREETOWN, SIERRA LEONE
January 2008




                                                                                                     5
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008


EXECUTIVE SUMMARY

In order to better address the seriously high number of maternal and child deaths
here in Sierra Leone there has recently been a significant shift in the approach to
RCH. There is now one comprehensive, evidence based RCH programme instead of
lots of separate, ad hoc, overlapping and/or duplication of, projects in reproductive
and/or child health. The overall goal of the programme is to make a significant impact
on reducing maternal and child mortality and morbidity through having a well
governed health sector and efficient health system with responsive service delivery
by stakeholders. This Reproductive and Child Health Strategic Plan 2008 – 2010
outlines the RCH strategies and actions needed to ensure that Sierra Leone stays on
course to achieve the Millennium Development Goals. As Sierra Leone is a post
conflict country undergoing rapid change this first strategic plan only covers a period
of three years.

The plan was developed in line with the recommendations of an international
conference that took place in London December, 2005 where the focus was on
achieving the MDGs 4, 5 and 6. One of the conclusions of this conference was that a
country like Sierra Leone will not achieve the MDGs without country specific
strategies that will need significant external support to be implemented. Such a
strategy would involve rapidly scaling up high impact, cost-effective interventions in
order to reach the relevant MDGs. It was also recognized that significant
improvements in human resources for health will be needed if these interventions are
to be successfully implemented. Another important recommendation was the
establishment of national committees on child survival and maternal health to provide
leadership and oversight for the process.

Subsequent to the conference the Ministry of Health and Sanitation conducted a
situational analysis. This was used in conjunction with the reports from other studies
to develop reproductive and child health policies, which in turn formed the basis for
the development of this reproductive and child health strategic plan. A National
Health Policy Advisory Committee was formed to oversee the development of all
policies and plans, whilst a National Steering Committee for Sexual, Reproductive
and Child Health was formed to guide the development of this plan and report to the
National Health Policy Advisory Committee.

Sierra Leone has long been considered one of the poorest countries in the world, and
the situation was further exacerbated by the decade long civil war that engulfed the
country from 1991. In close collaboration with development partners, the
government developed various strategies such as the National Recovery Strategy
and the Poverty Reduction Strategy to assist with post-war recovery and
development. A principal focus has been on decentralization with phased devolution
to the revitalised district and local councils. The focus was based on the results of
several studies that showed that over-centralization and the demise of the district and
local councils contributed significantly to the country’s socio-economic deterioration
that culminated in the civil war.

The goal of this RCH strategic plan is to reduce maternal, under-five and infant
mortality rates by 30% of the 2005 values by 2010 by providing comprehensive,
quality reproductive and child health services and strengthening the health system.
The objectives are to significantly increase the numbers of MCH Aides, SECHNs and
CHOs; ensure facilities have essential equipment and are functioning efficiently;
increase utilization of RCH services; ensure appropriate laws, regulations, rules and
guidelines are developed and enforced; contribute to more effective monitoring and
evaluation; ensure effective governance and management across the health system;


                                                                                                     6
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008


and ensure adequate coordination of work at all levels of the health system. To help
achieve these objectives eight strategies, each with its relevant, strategic actions
have been developed as follows:

    1. Effectively implement the reproductive and child health components of the
       package of essential basic services through improving coverage and
       utilization especially at community level;
    2. Improve the quality of reproductive and child health services through
       addressing supply and demand issues;
    3. Have the right people in the right place at the right time with the right skills to
       deliver RCH services through developing the policy and strategy context of
       human resource development, introducing and implementing the direct
       midwifery training programme, upgrading the training of SECHNs, scaling up
       the intake of current midwifery and MCH aides programme and helping
       improve the morale of health workers
    4. Achieve results through helping strengthen institutional, systems and
       management development at central and local government levels;
    5. Reduce the RCH related mortality and morbidity of malnutrition, malaria, HIV/
       AIDS and TB through working closely with the relevant programs to scale up
       cost effective and high impact interventions;
    6. Ensure the planning, monitoring and evaluation of RCH is integrated within
       the national systems through contributing to development of a robust M&E
       system and incorporating findings into planning;
    7. Effectively address relevant cross-cutting issues through improved
       coordination and collaboration mechanisms; and
    8. Undertake relevant operational research that contributes to RCH evidence
       based decision making through commissioning priority studies.

The risks to successful implementation include decrease in funding to the sector
because of poor macro-economic performance and/or donor fatigue; non-
improvement of literacy levels, especially among girls; insufficient attention to equity,
accessibility, utilization and quality of care; insufficient numbers of staff, especially
MCH Aides and SECHNs who contribute significantly towards delivering the basic
package of essential RCH services; and delays in recruitment of trained staff.
Assumptions include continuing political stability, strong political commitment,
increase in resources allocated to the sector, by the government as well as by
development partners; motivated health staff; and continuation of effective
partnerships among all stakeholders.

The estimated costs of implementing this RCH strategic plan are higher than the
costs of implementing the three year rolling plan, but lower than the MDG estimates
done by the government mid 2007. If successfully implemented, this plan is
expected to have a transformational effect on our development efforts in the health
sector, especially in the fight to reduce the extremely high child and maternal
morbidity and mortality indicators.




                                                                                                     7
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008


ACKNOWLEDGEMENTS

Numerous stakeholders contributed to the development of this RCH strategic plan.
Principal among these are the UN agencies led by UNICEF, WHO, and UNFPA.
UNICEF must be singled out for thanks because of the significant role played not
only as a driving force behind the process, but also for funding local and international
consultants, workshops and attendance at international conferences. The World
Bank and DFID provided support through funding people to attend international
workshops on marginal budgeting for bottlenecks and providing international
consultants. It is worthy to note that the World Bank and DFID have also already
committed significant funding for the implementation of this plan. The MoHS is
extremely grateful for this commitment on behalf of the beneficiary communities.

The 2007 annual health review and planning workshop provided an opportunity for
many stakeholders in the health sector to participate in the development of this plan.
The numerous suggestions and recommendations emanating from the discussions
during the group and plenary sessions were taken into consideration and definitely
enriched the plan, making it more relevant to the needs in the sector. Gratitude is
therefore extended to all those who attended the workshop and actively participated
in the various sessions on the RCH strategic plan.

The cooperation and support of the communities visited during the various stages of
the development of this plan was crucial. This is gratefully acknowledged whilst
simultaneously soliciting their continuing cooperation and support, which is vital if the
plan is to be successfully implemented.




                                                                                                     8
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008


CHAPTER 1. INTRODUCTION

This RCH strategic plan 2008 – 2010 gives the direction and scope of work of the
Sierra Leone Ministry of Health and Sanitation (MoHS) for the RCH programme. It
helps answer the question ‘how are we going to successfully achieve the 2007
reproductive health policy and the 2007 child health policy. It outlines how all
stakeholders can contribute to improving and sustaining the health of women and
children including adolescents in the country. It does not provide detail on
implementation. Such detail can be found in annual district plans and the plans of
other national programmes.

This chapter first brings to the attention of the reader just what is different and new in
this strategic plan. It then gives the key message that it wants to convey. This
message is not a technical one; it is one that emphasises political and other factors
that are vital to help ensure successful implementation. The second section outlines
the processes involved in developing this strategic plan. The final section highlights
that there are important contextual issues such as politics, poverty, cross cutting
topics, coordination and aid effectiveness that affect RCH.

1.1     What is different and new and what is the key message?

What is different and new?
The goal of the RCH programme 2008 -2015 is to make a significant impact on
reducing maternal and child mortality and morbidity through having a well governed
health sector and efficient health system with responsive service delivery by
stakeholders. A focus on responsiveness of the health services is new.

The key shift from the old to the new approach of implementing RCH interventions is
that there is now one MoHS RCH programme. There will no longer be lots of
separate, ad hoc, overlapping and/or duplication of, projects in reproductive and/or
child health. Furthermore, the programme is evidence based and therefore includes
cost-effective interventions. Both these approaches will facilitate a standardised
approach to RCH service delivery.

In addition, the added value is that the programme brings a significant change in the
health sector response to the seriously high maternal and child mortality. The
elements of change can be summarised as follows:
     The programme provides a clear message for saving the lives of women and
        newborns and of children. For women and newborns, focus on
        comprehensive reproductive health services, skilled care during and after
        pregnancy and childbirth and emergency care when life-threatening
        complications develop. For children, focus on preventive and other primary
        health care work such as immunisation and on the integrated management of
        neonatal and childhood illnesses. Put another way, to reduce the seriously
        high maternal mortality the crucial need is for the availability of 24 hour
        emergency obstetric care in all district hospitals and upgraded peripheral
        health units. To reduce the under-five mortality rate most of the prevention
        and care can be provided through primary health care especially at the
        community level (also see annex C).
     This strategic plan identifies specific RCH strategies and strategic actions, a
        mix of health service delivery and health systems/institutional development
        issues (also see chapter 3 and annex A). The sum total of the strategies and
        actions should contribute to helping improve the quality of life of women and
        children over the next 3 years.



                                                                                                     9
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008


       To make an impact both health service implementation and health
        system/institutional development work need to be undertaken simultaneously,
        at national level institution wide and at district level in all districts. The need
        for simultaneous work, in all districts, means that for health services there will
        need to be a rapid scale up, almost a big bang approach, to implementing the
        high impact, low cost, evidence based interventions. This is new. Change
        management is not amenable to such an approach so the institutional/health
        system changes will be on an incremental basis, but should not lag behind.
       If there are insufficient funds then resource allocation should be distributed on
        a proportional basis according to the priority ranking of the strategies that can
        be found in section 3.2 and in the strategic plan framework at annex A.
       Another wider contextual issue is the intention to strengthen synergies
        between health and other sectors critical to the survival of women and
        children - education, economic empowerment and rights being the core ones
        - through improved inter-ministerial collaboration
       The RCH strategic framework at annex A is a new way of looking at key
        elements of this RCH strategic plan, it provides a comprehensive perspective
        that:
             - Puts this strategic plan within the context of the reproductive and the
                 child health policies. At the policy level outcomes are given which is
                 new. They will contribute to achieving the millennium development
                 goals (MDGs)
             - Gives a strategic objective and planned outputs to work towards
                 achieving within a 3 year time frame
             - Gives outputs for each of the strategies with indicators towards
                 achievement, strategic actions and who has lead responsibility for
                 each of the strategies. This is also new.
             - Is a useful new tool for the mid-term review and then evaluation of the
                 strategic plan towards the end of year 3
       This strategic plan is linked to the MoHS medium term rolling plan and budget
        and it has been costed. A summary of the cost of the plan can be found at
        annex D and the full costing exercise is in volume 1. This is the first ever
        strategic plan in the health sector with a detailed costing.
       The strategic plan emphasises that the monitoring and evaluation (M&E)
        necessary to inform stakeholders of progress towards successfully achieving
        the planned outputs must be undertaken within the framework of the national
        M&E programme. Further information on this can be found in volume II.
       Volume III provides standards for reproductive health service delivery, criteria
        for ensuring quality and the minimum acceptable level of performance.

The key message
Crucial to achieving results through the implementation of this RCH strategic plan
that aims to make a difference, for the better, to the health of women and children
are:
     Strong, sustained political will and commitment
     Effective leadership by the MoHS
     Ownership by all stakeholders and partnerships with donors, agencies, NGOs
        and others
     International donor harmonisation and commitment to providing financial
        resources to implement this strategic plan
     Simultaneous health service and health systems strengthening
     Community participation
     Additional human resources for RCH and their better morale and retention
     Effective and efficient decentralisation


                                                                                                   10
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008


         Removal of barriers to accessing health services

1.2      Strategic plan development process
In December 2005, an international conference was held in London on the
‘Countdown to 2015 Child Survival’ attended by MoHS personnel and UNICEF. The
conference recommended that national governments should develop country led
maternal, newborn and child health strategies; mobilise resources from both partners
and governments; and ensure their efficient utilisation to implement the strategy. It
further recommended the development and strengthening of outcome oriented health
systems; strengthening of child survival and maternal health policies and programs;
and rapidly scaling up high impact cost-effective interventions in order to reach the
MDGs 4, 5 and 6. Furthermore, in order to have the necessary human resource to
develop and implement the recommendations, it called on governments of these
countries to adopt appropriate human resources for health strategies to address the
brain drain. The conference also recommended the establishment of national
committees on child survival and maternal health to provide leadership and advocacy
for the implementation of the recommendations.

Following attendance at the conference the MoHS conducted, in 2006, a situation
analysis of women and children in the country with support from UNICEF. Based on
the recommendations of the situation analysis, a reproductive health policy, a child
health policy and this RCH strategic plan have been developed as part of the road
map towards achieving the health MDGs.

To oversee the process of developing policies and strategic plans, a National Health
Policy Advisory Committee (NHPAC) was formed. At the same time a National
Steering Committee for Sexual, Reproductive and Child Health (NSCSRCH) was
established to guide the development of this strategic plan and report to the NHPAC.
The NSCSRCH, with multisectoral stakeholder representatives has developed this
strategic plan through a consultative process at different levels of the health system.
This has enabled stakeholders to contribute to designing the essential elements of
the RCH programme. The MoHS has led the process with international and national
technical assistance provided by UNICEF, DFID and other development partners
helping facilitate the development of the strategic plan.

This reproductive and child health strategic plan has also been developed within the
framework of the:
     2002 National Health Policy and ongoing discussions about the possible
        content of a new National Health Policy 2008 – 2015
     Current discussions about the new National Health Strategic Plan 2008 –
        2015
     Reproductive Health Policy 2007 - 2015
     Child Health Policy 2007 - 2015
     MoHS Medium Term Rolling Plan and Budget 2007 - 2009
     2004 poverty reduction strategy programme (PRSP)
     International evidence based/cost effective public health interventions

1.3       Overview of the reproductive and child health strategic plan context

Political context
There is a political commitment to health by the Government of Sierra Leone (GoSL)
in so far as health is core under 3 of the 5 pillars which form the basis for the 2004
poverty reduction strategy programme (PRSP). Gender and children have a high
profile with a Ministry of Gender and Children’s Affairs and Ministry of Social Welfare.



                                                                                                   11
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008


The GoSL also has an obligation towards its citizens through having ratified human
rights conventions. For example, it has ratified the Convention on the Elimination of
All Forms of Discrimination against Women and the Convention on the Rights of the
Child.

The 2007 election manifesto of the party elected to govern in the latter part of 2007
refers to basic health care as a core principle as can be seen from the following full
list of principles:
      Democracy and good governance
      Freedom, human rights and human dignity
      Justice, equality and the rule of law
      Integrity, transparency and accountability in the conduct of public affairs
      Long term sustainable development through dependable, appropriate
         housing, sound education, basic health care, abundant food production,
         appropriate housing, increased youth employment, improved infrastructure,
         efficient transport and efficient services’.

The manifesto has a section on ‘Health, nutrition and sanitation’ in which the party
pledges if elected, various commitments. Those of direct relevance to RCH include:
‘providing affordable health care services….fully empowering local council authorities
to take up their responsibility for the delivery of health services…..pay attention to
areas of the country prone to high levels of infant and maternal mortality….increase
awareness of HIV/AIDS and of family planning…and revisit the cost recovery
scheme’. In the section on water there is a commitment to ‘cut down on water borne
diseases by introducing water and sanitation programmes throughout the country’.
And the section on empowering women has a commitment to ‘ensuring that women’s
issues are mainstreamed across all development and public policy processes’.

In November 2007 news on the internet highlighted that the report of a confidential
presidential audit commissioned by the new president ‘Catalogues grave
inadequacies in key areas such as health care, tax collection and the security
services’. There is a Parliamentary Committee on Health. Some members attended
the November 2007 Annual National Health Review and Planning Workshop and
contributed to the finalisation of this RCH strategic plan.

Poverty context
Sierra Leone is an extremely poor country with a GDP per capita of only $600, an
external debt of $1.5 billion and an economy that is mainly donor driven. The 2004
PRSP gives an estimate of 70 per cent of the population living below the poverty line
of US$1 per day. In 2007 Sierra Leone bottom of the UNDP Human Development
Index, 177th out of 177 countries. The very serious situation in health and education
were major factors that helped determine the terrible ranking.

Some of the results of the Sierra Leone integrated household living conditions survey
(SLIHLCS, 2004) have a direct impact on the health of women and children. For
example:
    More women live in poverty in Sierra Leone than men, 69 percent of female
      headed households are poor against 59 percent of male headed households
    There are a growing number of households in Sierra Leone headed by
      women, and these households are disproportionately poor
    Women tend to have lower education, (90 percent of mothers in the lowest
      quintile had not completed primary education), limited access to productive
      resources, a narrower range of formal sector labour market opportunities, and
      lower wage rates than men.



                                                                                                   12
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008



When the 10 years of civil war came to an end in 2002 the Government of Sierra
Leone wrote a national recovery strategy. It acted as a bridge between emergency
humanitarian assistance and longer term development. Following its approval Sierra
Leone qualified for debt relief under the World Bank Highly Indebted Poor Countries
Initiative (HIPC). The government, in close collaboration with development partners,
then developed and implemented an interim poverty reduction strategy programme
(I-PRSP). Since 2004 it has been implementing a full PRSP. In Box 1 are some
findings on health from the 2004 PRSP document. All these issues impact on
reproductive and child health. As part of the PRSP there are now 3 year rolling plans
under the GoSL’s medium term expenditure framework (MTEF), for example, the
MoHS Medium Term Rolling Plan and Budget 2007 – 2009. There will be a new
PRSP in 2008. Some of the issues addressed in this RCH strategic plan will feed into
the PRSP via the new national health policy and national health strategic plan.

Of direct relevant to RCH was the Post 2002 Presidential Decree that stated that the
following vulnerable groups be exempted from paying fees for basic health services
in the public sector:
      Pregnant women
      Breast feeding women up to 12 months after birth
      Children under 5 years of age
      School children up to senior secondary school
Other people also covered by this decree are those with disabilities, those aged 65
years and more and the destitute.

There are also exemptions for some other services. But it is generally acknowledged
that the exemptions mechanism is not well implemented and there are also under-
the-table payments. Debate started in 2007 as to whether user fees should be
abolished.

Preliminary findings released November 2007, of the national health accounts (NHA)
stated that the majority of health funds came from household out-of-pocket
expenditure, 69.2 percent in 2006. The per capita out-of-pocket expenditure in 2006
was estimated at Leones 129, 347 or US$43.30. If this extremely high level of per
capita out-of-pocket expenditure is accurate then many households may be exposed
to the risk of financial catastrophe and impoverishment including serious levels of
debt. At the time of writing this strategic plan it is unknown what percentage of the
out-of-pocket expenditure goes on RCH.



        Box 1. Some health sector findings in the 2004 PRSP document
        Resources for the health sector were deemed to be totally inadequate,
        even to deliver a basic level of health care
        Resources for health were unevenly distributed throughout the country
        which raised questions on equity of distribution and access:
            The top quintile, richest 20%, of the population account for 46%
                 of the national household consumption on health (SLHICLS

                 2004).

             The bottom quintile, poorest 20%, of the population account for
                7% of the national household consumption on health (SLHILCS
                2004).
            Western Area average household size is 6.03 with the largest
                 per capita annual consumption on health at Le.263, 541.00
                 (approx. $105)
             Kambia district average household size is 6.84 with the lowest
                 per capita annual consumption on health at Le.26,382 (approx.
                 $10.55)                                                                           13
        Criteria for allocation of resources and indicators measuring the
        performance of the sector did not fully address issues of equity and
        gender.
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008




Millennium development goals
The Government is committed to achieving the MDGs. This is a formidable challenge
given the negative impact of 10 years of civil war. Key challenges lie in:
     Ensuring an effective and efficient management environment within which the
        necessary systems and services are developed and their implementation
        accelerated given the relatively short time frame that now remains until 2015
     Human resource development
     Adequate resources including finance

Table 1 shows the key health and health related MDGs, the levels in 2000 and 2005
and the targets for 2015. The July 2007 draft report on reaching the MDGs by the
Development Assistance Coordination Office (DACO) of the Office of the Vice
President states that Sierra Leone needs a total of US$1,114 million between 2007
and 2015 to reach the health MDGs. The annual costs can be seen in Table 2. More
specifically, the costs for reaching the targets in maternal and reproductive health,
child health, malaria and tuberculosis can be seen in Table 3. In Table 4 is the cost of
reaching the HIV/AIDS target.

Table 1: Health and health related MDGs and the targets for 2015 in Sierra
Leone
MDG                   2000 level*                    2005 level*                    Target 2015
Reduce child          Under- fives mortality rate:   Under-fives mortality rate:    Under- fives mortality rate: 95
mortality             286 per 1,000 live births      267 per 1,000 live births      per 1,000 live births
Reduce maternal       Maternal mortality ratio:      Maternal mortality ratio:      Maternal mortality ratio:
Mortality              1,800/1000,000 live births    1300/100,000** live births      600/1000,000 live births
Reduce proportion     Underweight prevalence:        Underweight prevalence:        Underweight prevalence:
suffering from        27.2%                          31%                            <20%
hunger                Exclusive breast feeding       Exclusive breast feeding       Exclusive breast feeding rate
                      rate (0-5 months): 2.4%        rate (0-5 months): 8%          (0-5 months): 75%
Improve access to      Contraceptive                 Contraceptive prevalence:       Contraceptive prevalence:
safe contraception    prevalence: 3.9%               5%                             15%
Combat HIV/AIDS        Higher risk sex in last       Higher risk sex in last year    Higher risk sex in last year
                      year (15-25 year olds):        (15-25 year olds): 43%         (15-25 year olds): 22%
                      N/A
                      Condom use with non-           Condom use with non-           Condom use with non-regular
                      regular partners: N/A          regular partners: 20%          partners: 40%
Reduce incidence of   Malaria-under fives            Malaria-under fives            Malaria- Under fives sleeping
malaria and other     sleeping under insecticide-    sleeping under insecticide-    under insecticide-treated nets:
communicable          treated nets: 1.5%             treated nets: 5%               75%:
diseases              Fully immunized children       Fully immunized children       Fully immunized children
                      (within first 12-24            (within first 12-24 months):   (within first 12-24 months):
                      months:%                       35 %                           90%
                      BCG immunisation               BCG immunisation               BCG immunisation coverage:
                      coverage: ?72.8%               coverage: 84%                  95%
                       DPT 3 immunisation            DPT 3 immunisation             DPT3/Penta immunisation
                      coverage: 57%                  coverage: 57%                  coverage: 90%
                      Measles immunisation           Measles immunisation           Measles immunisation
                      coverage: 61.7%                coverage: 63%:                 coverage: 93%
Water and             Use of improved drinking       Use of improved drinking       Use of improved drinking water
Sanitation            water sources: N/A             water sources: 47%             sources: 62%

                      Use of improved sanitation     Use of improved sanitation     Use of improved sanitation



                                                                                                                 14
         Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
         Plan 2008 -2010, January 2008


                             facilities: N/A       facilities: 30%          facilities: 75%
         Education           Net primary school    Net primary school       Net primary school attendance
                             attendance rate: N/A  attendance rate: 69%     rate: 100%
         * Baseline data (except for 2005 MMR) from Sierra Leone Multiple Indicator Cluster Surveys
         (MICS) 2000 and 2005; ** MICS adjusted, MoHS, UNICEF et al, 2007

         Table 2. Total costs of achieving health MDGs (in million US$)
                                                                                                                             20
                             2006      2007       2008       2009         2010     2011        2012     2013      2014       15

TOTAL MDG HEALTH                                                                               143.     132.                 16
SECTOR (million$)            70.7      101.7      127.0      122.0        139.3    139.7       3        3         152.4      0.0

PER CAPITA HEALTH                                                                              23.7     21.3                 24.
SECTOR COST ($)          13.56     19.04   23.19             21.75        24.24    23.72       4        7         24.00      59
Average Cost Per
Capita ($)               22.1
           Source: MDG NA and costing, June 2007

         Table 3. Partial costs of meeting specific health targets (in million US$)
                     2006    2007      2008      2009       2010        2011       2012       2013        2014       2015
 Maternal
 and
 reproductive
 health              6.252    6.459    6.124      6.454      6.826       7.465      8.038      8.607      9.231          9.508
 Malaria
 prevention          7.876    0.706    0.971                 8.749       7.233      0.027                 9.174          8.039
 Malaria
 treatment        4.982       7.297    8.189      9.452     10.320     10.220      11.784     11.274     12.094      11.296
 Child health    10.989      12.268   12.113     11.032     11.717     12.426      13.966      4.273     15.622      15.848

 Tuberculosi
 s            0.388   0.476    0.559    0.592                0.621       0.647      0.669      0.688      0.701          0.710
        Source: MDG NA and costing, June 2007



         Table 4. Required financial resources to meet HIV/AIDS MDG target
                     2006 2007     2008    2009   2010    2011     2012    2013                        2014        2015
        Prevention 2.904 3.863     4.983   6.156  7.423   8.722 10.109 11.583                          13.125     14.644
        Treatment 0.014 0.016      0.019   0.022  0.025   0.027    0.030   0.033                        0.036      0.039
        Care and
        support      4.070 4.777   5.438   6.128  6.839   7.736    8.786 10.074                        11.736     12.809
        Total
        costs        6.988 8.657 10.440 12.306 14.286 16.486 18.925 21.691                             24.897     27.492
        Cost per
        capita        1.34   1.62   1.91     2.19  2.49    2.80     3.13    3.50                         3.92       4.23
         Grand Total: $162,167,111   Source: MDG NA and costing, June 2007

         Institutional and health systems development
         It is increasingly being acknowledged that effective and efficient institutions and
         health systems are crucial to the delivery of quality health services. There are no
         institutional or health system issues specific to RCH, they apply to the MoHS as a
         whole. So some of the donor money for RCH will need to be spent institution wide on
         simultaneously helping strengthen issues such as the following:
               Leadership by example
               Sector wide governance



                                                                                                            15
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008


       Client focus and valuing staff
       Strategic decision making and pro-active, risk taking culture
       Incentives for creativity and innovation
       MoHS structure that reflects systems and processes as much as technical
        issues
       Clear roles, functions and responsibilities with a focus on comparative
        strengths and quality
       Transparent, participatory and accountable decision making structures and
        processes
       Useful coordination and harmonization mechanisms
       Effective, efficient quality systems such as procurement, budgeting,
        accounting, maintenance and communication
       Accountability, delegation and decentralisation
       Enforcement of laws and regulations

If such an approach is taken, strengthening the institutional and health system
context, then it will better enable the effective use of facilities and staff. The latter can
then more effectively use their skills and knowledge. If it does not happen and funds
only benefit the RCH directorate and those working on RCH issues then the
directorate and personnel will become little islands of technical excellence. And then
are highly frustrated when trying to get things done outside their RCH area as they
have had little or no influence on the ministry as whole, outside their door/subject it is
the status quo. The institutional culture and systems they are dependent upon in the
wider context to implement their different ways of working has remained unchanged.

Decentralisation
Post conflict studies have revealed that over centralization and the demise of district
and local councils contributed significantly to the socio-economic decline that
eventually led to the 10 year conflict. A local government act was therefore passed in
2004 and the Ministry of Internal Affairs re-named Ministry of Local Government.
The key implications and necessary actions for the MoHS were: a) the immediate
devolution of most primary health care (PHC) work to district councils including RCH;
and b) the transfer of all GoSL budgetary allocations for PHC to the Ministry of Local
Government. Hospital functions and services will be devolved to the councils in 2008.

There are no decentralisation issues specific to RCH. Decentralisation affects all
health services in the same way. For example, participants at the Annual National
Health Review and Planning Workshop, November 2007 identified the following key
issues that need to be addressed if decentralisation is to be more effective and
efficient:
      Clarify accountability and roles and responsibilities
      Strengthen coordination and communication
      Clarify linkages: technical, financial and political
      Better availability of funds; more efficient budgeting and accounting systems
      Make distinction between governance and management
      Clarify functions of hospital boards and consider need for regulation for the
         Hospital Boards Act
      Review functions of the district councils in relation to health

Cross cutting issues
The cross cutting issues of direct relevance to RCH are HIV and AIDS, gender,
water, sanitation and the environment.

HIV and AIDS


                                                                                                   16
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008


Issues in HIV and AIDS specific to RCH are prevention of mother-to-child
transmission, provision of paediatric AIDS treatment, safe blood for caesareans,
orphans and other vulnerable children. All these issues are addressed in the 2002
National AIDS Policy and in the successful Round 7 application for a Global Fund
grant. Also see section 2.3.
Gender
Key to better addressing gender within the context of RCH is the need to pay greater
attention to:
     Involvement of men and women together in discussions and decisions
     Ensuring more women are on community committees
     Making RCH services gender friendly
     Working with the Ministry of Gender and Children Affairs
     Development and enforcement of legislation
     Having client friendly services for rape victims, abortion, gender based
        violence victims and those with fertility problems and cervical cancer

Water, sanitation and the environment
Fundamental to helping prevent ill health among women and children is ensuring
access to adequate quantities of safe water supplies, the use of improved sanitation
facilities and good hygiene practices in the home. For the latter IEC/BCC is
important. Working with other relevant ministries, with district councils and
communities is important to improve water and sanitation facilities. There is nothing
specific about waste management as applied to RCH; all health workers need to
ensure the safe disposal of sharps and other medical supplies.

Coordination and partnerships
There are 2 key units in government responsible for the coordination of health. First,
the Central Aid Co-ordination unit at the Ministry of Finance and Development which
has overall responsibility for aid co-ordination and management including:
Registration of donor agencies and NGOS operating in the country
Setting the national development policy
Donor contact and co -ordination

Secondly, the MoHS Donor/NGO Liaison Unit, the focal point for all communication
and activities relating to donors and NGOs in the health sector. It has overall
responsibility for providing the necessary linkages between all stakeholders within
the sector. The 2007 MoHS vision paper on health coordination states that ‘The
existing office of the NGO-Donor Liaison office will be also responsible for the overall
coordination of all meetings of all committees/task forces’.

In 2007 the main health sector coordination mechanisms included:
     National Health Policy and Advisory Committee (NHPAC)
     National Health Sector Steering Committee (NHSSC)
     Health Development Partners Forum
     Christian Health Association of Sierra Leone (CHASL), the umbrella
       organisation for all Christian church health providers
     Country Coordinating Mechanism (CCM) for Global Fund to Fight AIDS, TB
       and Malaria
     Inter-agency Coordination Committee (ICC) for GAVI

Of great importance to RCH is inter-ministerial coordination/collaboration between
the MoHS and ministries of economy and development, gender and children, water,
transport, education, the environment/rural development and agriculture and food
security.


                                                                                                   17
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008



Since 2002 the main response to health sector development has been through the
implementation of many, often small, projects implemented by a variety of different
stakeholders. Sometimes the coordination mechanism has been weak and there has
been duplication of efforts. To further consolidate the harmonisation of all inputs from
all the development partners, the MoHS is moving towards a sector-wide approach in
the health sector. This RCH strategic plan is a step towards such an approach as it
consolidates all projects in RCH into one programme.

Principles of aid effectiveness
The Government of Sierra Leone, with its development partners is increasingly
addressing the 5 principles of aid effectiveness as found in the 2005 Paris
Declaration on Aid Effectiveness. The MoHS and its key international stakeholders
are particularly interested in applying all the principles. As applied to RCH the
principles are:

Ownership — as stated earlier the process for developing this RCH strategic plan
included a number of consultative meetings all over the country. It is hoped that as a
result of this there is strong ownership by the implementers of health care in
particular. MoHS has exercised leadership over the development of the RCH policies
and this strategic plan and its coordination. The key donors are showing support and
enabling government ownership by respecting the policies and strategic plan and
stating their intention to help strengthen capacity to implement them. And other
partners e.g. NGOs have stated their willingness to work within the framework of the
policies and strategic plan.

Alignment —the key donors have expressed their willingness to align as far as
possible their support with MoHS and government procedures.

Harmonization — the donors are synchronising, being more harmonized about, their
support for RCH. The intention being that the support is less burdensome to Sierra
Leone, through having one programme instead of numerous projects in reproductive
and/or child health. For example, early 2008 the UN will launch a joint programme in
support of the child and maternal health MDGs in Sierra Leone 2008 – 2010 that will
be implemented within the framework of the government’s RCH programme (UNDAF
2008). The 3 programmes are: 1) prevention and management of malnutrition,
UNICEF and WFP; 2) immunization UNICEF, WHO; and 3) comprehensive
emergency obstetric and neonatal care, UNICEF, UNFPA and WHO. All 3
programmes have common outputs:
     Support to policy development and planning
     Capacity building package, with focus on service providers
     Increased access and utilisation of services
     Monitoring and evaluation of the implementation and the impact

Managing for results — to address the need for a results orientated RCH
programme outcomes have been set for both the reproductive and the child health
policies. There are overall planned outputs for this RCH strategic plan as well as for
each of the 8 strategies in the plan. Indicators of achievement have also been set for
each of the strategies. The RCH planning and review processes are integrated within
the national planning and review/evaluation cycles. Management strengthening is
included as one of the strategies.

Mutual accountability — the MoHS and donors are planning to hold each other
mutually accountable for achieving results in RCH.



                                                                                                   18
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008


CHAPTER 2. WHERE ARE WE NOW IN REPRODUCTIVE AND CHILD HEALTH?
This chapter first defines reproductive health and child health so that we all have a
common understanding of the commonly used terms. It then informs the reader of
relevant documents available at the end of 2007. The next section highlights the
main issues in RCH, that are also challenges, that have been identified through the
various consultations as part of the process of developing this strategic plan. A
number of these issues are summarised in the SWOT analysis table that participants
did during the November 2007 Annual National Health Review and Planning
Workshop. The final section of this chapter shows the key RCH responsibilities at
each level of the health system as part of being more transparent about who is
responsible for what and where.

2.1     Definition of reproductive health and of child health

Reproductive health
The 2007 RCH policy states that ‘Reproductive health is a state of complete physical,
mental and social well-being and not merely the absence of disease or infirmity in all
matters relating to the reproductive system and to its functions and processes.
Reproductive health therefore implies that people are able to have a satisfying and
safe sex life and that they have the capability to reproduce and the freedom to decide
if, when and how often to do so’. In addition the definition states that ‘Reproductive
health care is the constellation of methods, techniques and services that contribute to
reproductive health and well being by preventing and solving reproductive health
problems. It also includes sexual health, the purpose of which is the enhancement of
life and personal relations and not merely counselling and care related to
reproductive and sexually transmitted diseases’.

Child health
There is no definition of child health in the 2007 child health policy but internationally
it is generally agreed that child health is concerned with the health of infants, children
and adolescents, their growth and development, and their opportunity to achieve full
potential as adults.

2.2     Current reproductive and child health policies, plans, acts and other
        documents
It can be seen form the following list that various useful RCH policies, plans,
standards and other documents have been developed over the past few years. This
RCH strategic plan is a tool to help close the gap between all the RCH policy and
other documents and effective implementation. The documents include:
      Reproductive Health Policy 2007 - 2015 (see also section 3.1)
      Child Health Policy 2007 – 2015 (see also section 3.1)
      RCH M&E (also see volume II)
      RCH norms and standards (also see volume III)
      The Domestic Violence Act, 2007
      2007 Contraceptive Commodity Security Strategic Plan 2007 - 2011
      Family Planning Commodity Procurement Plan 2007 - 2009
      MoHS Reproductive Health Division 2007 draft summary progress report,
        November 2007
      Reproductive health and socio-economic needs of young persons, 2005
      Vesico-Vagina Fistula Strategic Plan and Vesico-Vagina Fistula Programme
        Implementation Framework




                                                                                                   19
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008


2.3     Main issues in, and SWOT of, reproductive and child health

Health status of women and children
Post-conflict assessments of the health status of Sierra Leone have revealed some
of the worst maternal and child health statistics in the world. There is ongoing
discussion some would even say controversy about the maternal mortality ratio. The
MICS 2 result in 2000 was 1,800/100,000 live births with the 2005 MICS 3 result
given as 495/100,000 live births. Some people think the latter is too low and through
consultation the agreed figure was 1,300/ 100,000 live births. This figure is referred
to as the ‘2005 MICS adjusted MMR’. Whatever the figure the lifetime risk of death
from maternal causes is high.

Table 5 shows maternal mortality ratios for Sierra Leone and nearby countries in
2005. It highlights the seriously high maternal mortality in Sierra Leone. The rates
were derived from estimates on maternal mortality developed by the WHO, UNICEF,
UNFPA and the World Bank.

The main determinants in maternal and child illness can be seen in Figure 1. Here in
Sierra Leone other factors external to the health sector include poverty; low literacy
rates especially amongst girls and women and domestic and sexual violence. Early
marriage is also a factor sixty-two percent of surveyed women aged 15 – 49 married
before they were 18 years of age (MICS 2005). Factors within the health sector
include inadequate numbers of trained and motivated staff, absence of skilled health
personnel at birth, insufficient drugs, medical equipment and other supplies, poor
provision of emergency obstetric and neonatal care for complications and an
ineffective referral system (also see the SWOT of RCH services at table 6).


Table 5. Maternal mortality in Sierra Leone and nearby countries

                 Country                         Year              MMR (maternal deaths
                                                                   per 100,000 live births)*
       Gambia                                     2005                       690
       Ghana                                      2005                       560
       Guinea Bissau                              2005                      1,100
       Liberia                                    2005                      1,200
       Nigeria                                    2005                      1,100
       Sierra Leone                               2005                      2,100
* In the report MMRs have been rounded and figures computed to ensure comparability, thus
they are not necessarily the official statistics of countries, which may use alternative rigorous
methods.
Source: Maternal Mortality in 2005: estimates developed by WHO, UNICEF, UNFPA and The
World Bank. World Health Organization, 2005




                                                                                                   20
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008


Figure 1: Immediate, underlying causes and basic determinants of maternal,
neonatal and child illness


                              Maternal, Neonatal & Child Illness
                                                                                                  Manifestations


                                                                                                 Immediate
                     Malnutrition                                   Disease
                                                                                                 causes
                                    Care for women
               Insufficient      Breastfeeding/Feeding;                    Insufficient Health    Underlying
                                                                          Services & Unhealthy
                Household
              Food Security
                                  Psychosocial Care;                          Environment
                                                                                                  causes
                                  Hygiene Practices;
                                Home Health Practices

                                  Inadequate Education
                                     Resources & Control
                               Human, Economic & Organisational


                              Political and Ideological Superstructure
                                                                                                 Basic
                                                                                                 Determinants
                                         Economic Structure



                              Political, social and economic structures



Source: Child survival and maternal mortality in Sierra Leone – a situational analysis, 2006,
UNICEF

According to the 2006 situational analysis on child survival and maternal mortality by
UNICEF, the main medical causes of maternal mortality in Sierra Leone are:
haemorrhage (15 percent), obstructed labour (15 percent), ruptured uterus (11
percent), anaemia (15 percent), abortion (8 percent), eclampsia (7 percent), malaria
(6 percent) and ectopic pregnancy (4 percent) as can be seen in Figure 2. Another
factor common to both maternal and child mortality maybe the lack of safe blood for
transfusion for which there is a high demand. For example, in 2007 it was estimated
that at least 75 percent of all blood transfusions are for women and children.

It can be seen in the above paragraph that abortion is estimated at 8 percent. There
are no reliable data on the incidence of unsafe abortion and unsafe abortion related
maternal deaths in Sierra Leone. However, from global figures on cause of death
attributable to complications due to unsafe abortion, it can be extrapolated that at
least 13 percent of the country’s maternal deaths result from unsafe abortion, of
which adolescents constitute 25 percent. The current legislation on abortion is too
restrictive.

Most of the causes of child mortality are preventable, for example, malaria (33
percent), diarrhoea (29 percent), and pneumonia (14 percent). These 3 illnesses
account for over three quarters of all childhood deaths. Malnutrition is the biggest
contributor to the child mortality, 46 percent of all deaths in those under 5 years of
age. Child under-nutrition rates are over thresholds considered as critical by WHO
i.e. prevalence of 30 percent underweight or more.
HIV is emerging as another contributory factor for both maternal and child mortality.


                                                                                                                   21
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008


The following pie chart shows the major causes of under-five mortality in Sierra
Leone.



                            Figure2: Causes of Under-five Child Mortality
                                       in Sierra Leone, 2005



                                             Others, 3%
                                    Neonatal, 19%
                                                                         Malaria, 33%


                                                    Malnutrition
                                    Pneumonia,
                                                       46%
                                       14%

                                      measles, 2%
                                                          Diarrhoea,
                                                             29%




Figure 3. Major medical causes of maternal mortality in Sierra Leone
                                                                   , 6%
                                                                    ia
                                                                lar
                                                              Ma




                                           others, 3%
                                                                         HIV/AIDS, 2%
                                  Heamorrhag
                                                                               Anaemia,
                                    e, 15%
                                                                                 15%


                                                                                 Ectopic
                               Obstructed                                      Pregnancy,
                               Labour, 15%                                          4%
                                                                              Abortion, 8%

                                       Ruptured                           Eclampsia,
                                                         Pueperal
                                       Utrus, 11%                             7%
                                                        Sepsis, 6%




Source: Child survival and maternal mortality in Sierra Leone –a situational analysis, 2006,
UNICEF

Cultural and social issues
Women generally have a low social status in the country. Furthermore, illiteracy is
very high among women, higher than the national average of 20%. Both these
factors result in lack of female empowerment.

Socially, the most vulnerable in RCH are female headed households, rape victims,
people living with HIV or AIDS and orphans and out of school children/adolescents.




                                                                                                   22
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008


Practices detrimental to health are still very pervasive. As an example, in Kabala
Township over 90% of deliveries happen at home. Coupled with the poor economic
status of this community, it is not surprising that 58% of peri/neonates are placed on
the floor after delivery. This is indicative of the unhygienic home birthing and cord
care practices prevalent in this community; a possible source of infection with
neonatal tetanus.

Traditional healers are found in all villages as they constitute an integral part of the
local community. Due to cultural preferences, acceptability and accessibility, both in
physical and financial terms, they usually provide the first form of consultation for the
mother or neonate with complications, especially in the very remote areas.
Misconceptions that compromise the exclusivity and maintenance of breastfeeding
are also very common. These include the use of pre-lacteals e.g. water or herb
extracts to hasten meconium passage and discard of the colostrum.

According to a survey conducted in 2003 by the Centers for Disease Control and
Prevention, Atlanta, USA, the World Bank and the GoSL, gender based violence
(GBV) is common in Sierra Leone. Prevalence of physical and sexual assaults and
harmful traditional practices, in particular female genital mutilation/cutting (FGM/C) is
high. Indeed, sexual violence is widely regarded to be of near endemic proportions in
the country. The majority of physical and sexual assault victims are female and the
perpetrators are, in most instances, a male relative or friend. Data from 3 sexual
assault referral centers in Sierra Leone showed that the vast majority of sexual
assault victims are adolescents aged 11 to 15 years (60 percent) and pre-
adolescents aged 6 to 10 years (23 percent). The practice of FGM/C is highly
prevalent with 94 percent of young women having undergone FGM/C.

One cause of gender-based violence/domestic violence is likely to be infertility. The
prevalence of infertility is unknown in the country. But it is a major RH problem in the
West African sub-region. Sierra Leone is likely to be no exception (see also volume
III).

Barriers to accessing health care

Women’s socio-economic status: A woman’s status in her community generally
underlies and shapes her access to health services. Studies in Ethiopia, Nigeria and
India indicate that women do not decide on their own to seek care without the
approval of a spouse or senior members of the family. This has also been found to
be the case in rural communities in Sierra Leone. A report in 2004 of a study
undertaken by the NGO CARE states that in focus group discussions, 68 percent of
the mothers said that the decision on the place of delivery is usually made by the
husband at the onset of labour. In the absence of any forward planning, many
deliveries take place in the home, usually delivered by family members.

Children and adolescents
About 11 percent of children, which includes adolescents, are orphans and 20
percent of children/adolescents do not live with their biological parents (MICS 2005).
This exposes such vulnerable children to rights violations, including their right to
health care. It was mentioned earlier that the majority of assault victims are
adolescents aged 11 to 15 years (60 percent) and pre-adolescents aged 6 to 10
years (23 percent). These figures are of self referral people who went to special
centres for victims of violence and should therefore be treated with caution. However,
they may indicate a serious problem in the community.




                                                                                                   23
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008


Distance and physical access: The distance separating potential patients from the
nearest health facility has been shown to be an important barrier to seeking health
care in rural areas in Sierra Leone. With an 11 mile average distance to the nearest
health facility and the inequitable distribution of health facilities due to poor planning
and self interests, combined with difficult terrains such as mountainous and rivers
and very poor road network systems provide formidable barriers to accessing health
care. They result in some people having to travel long distances to the nearest health
facility. And also mean that outreach is sometimes impossible in remote scattered
settlements

Cost: A major factor in decision making about seeking RCH and other care for many
people in the country is the financial cost. It is a major barrier as most families cannot
afford the cost of health services or transportation to seek health care. As stated in
section 1.2 a number of vulnerable groups are exempted from paying fees for basic
services. However, 30 – 40 percent of staff working in peripheral health units (PHUs)
are not formally employed. They are either health workers who have completed their
training but are not yet employed. Or are volunteers without any formal training who
are working as nursing aides or vaccinators. This has led to unofficial charges in both
hospitals and PHUs to generate funds to pay such personnel.

Orphans and children living with caregivers other than their biological parents run a
high risk of not getting the health care they need. This is because parent tends to
spend their little money on their own children rather than on other children in their
household when there are financial constraints.

Quality: is an important factor in the decision to seek care in Sierra Leone.
Generally, most RCH services are not very client friendly, a good reflection of the
quality management. Safe practice is an indication of quality of care. Examples of
where safe practice is needed are. blood and vaccination safety, safe sharps
disposal and infection management in particular need further attention.

In Kabala Township, even though health facilities and obstetric care are physically
more accessible, the quality of care is poor. For example, the percentage of mothers
with two or more antenatal visits is only 56 percent with just 19 percent of pregnant
women receiving the second tetanus toxoid (TT) immunisation in 2005. Low staff
competence leads to missed diagnosis and suboptimal clinical management as
observed in other countries. In a study in Zimbabwe, missed diagnosis and
inadequate management by incompetent staff as being responsible for 87% of
maternal deaths, and by extension peri/neonatal deaths, in a rural community. Some
people think that there may be a similar situation here in Sierra Leone.

Accounting for quite a significant proportion of stillbirths, maternal and neonatal
deaths in Sierra Leone are delays in receiving prompt, adequate and appropriate
treatment in a referral hospital. The quality of care in such a facility can be untimely,
ineffective, unresponsive or discriminatory, and is often financially prohibitive.

Poorly staffed facilities
A common problem is acute shortages in the number of trained and qualified
personnel at health facilities. For example, MoHS data shows that in 2007 there was
a shortfall of 113 midwives and 272 MCH Aides (see table 6). This leads to long clinic
waiting times and high opportunity costs to clients especially in rural areas.

Ill-equipped facilities
The absence of adequate supplies such as fuel, drugs, other medical supplies and
transport also constitute barriers to accessing health care.


                                                                                                   24
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008

Table 6. Examples of staff shortfalls
Staff category 1993 2006 2007                 Vacancies           Gap
Medical         203      88     64               300              236
officers
Medical          98       5      7                 30              23
specialists
(clinical)
Medical          58      22     21                 30               9
specialists
(public
health)
State             ?      57     87                200              113
registered
midwives
Clinical          ?     202    225                600              375
nurses
Pharmacists       ?      14     17                 30               13
MCH aides         ?     980 1,228                1,500             272
Source: MoHS RCH Directorate, 2007

Communication
Poor communication systems are playing a key role in hampering efforts to get an
ambulance for those who need to be urgently referred to a health facility.
Communication, or lack of, is also contributory factor in poor staff morale. For
example, a currently common situation is that a health worker in a peripheral health
unit has a patient with a serious life threatening condition but has no means to
contact someone in a district hospital for advice and support. In such circumstances
morale is bound to be affected and eventually when it happens once too often then
burn out occurs.

Inability to recognise danger signs in the mother or signs of illness in the
neonate:
Studies in Sierra Leone indicate that many women are not aware of danger signs in
pregnancy/delivery or in sick children and the need for timely intervention. Pregnancy
and child birth are regarded as natural processes, and signs and symptoms of
complication or illness are not always regarded as life threatening emergencies. It is
a widely held belief in rural areas that obstructed labour is caused by a woman’s
infidelity. So time is wasted in trying to obtain a confession thereby endangering the
life of the mother and child.

Nutrition, malaria, TB and HIV/AIDS
Nutrition
A little earlier it was highlighted that malnutrition accounts for 46 percent deaths in
children. The MICS 3 gives the underweight prevalence rate as 30 percent, higher
than the 27.2 rate for MICS 2. Lack of breastfeeding, especially exclusive
breastfeeding during the first five months of life, and inappropriate complementary
feeding are important risk factors for infant and childhood morbidity and mortality.
Only 5 percent of babies are exclusively breastfed in Sierra Leone and
complementary feeding is either started too early or too late. And the foods used are
often nutritionally inadequate and unsafe.

A greater burden of diarrhoeal diseases, measles, malaria and lower respiratory
infections in childhood can be attributed to under-nutrition. Cultural food taboos, the
lack of knowledge of the nutritional values of foods, food self-sufficiency, poverty and
the favour accorded the men in the intra-household distribution of food contribute
immensely to child malnutrition.


                                                                                                   25
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008


Malaria
As stated earlier, according to the 2006 UNICEF situational analysis, malaria
accounts for 33 percent of child deaths and 6 percent of maternal mortality. Children
under 5 years and pregnant women therefore form a major target of the national
malaria programme. The objective is to reduce morbidity and mortality amongst them
by 25 percent and 35 percent respectively by the end of 2008. This is to be achieved
through collaboration with the RCH and other programmes. The main aim is to
harmonize treatment protocols and promote joint activities to scale up malaria
prevention and control activities for children under 5 and pregnant women.
Particularly in the area of insecticide treated net (ITN) distribution during EPI and
antenatal activities, capacity building of health providers and communities and the
provision of treatment guidelines and other support systems for effective
implementation of the RCH programme.

TB
In Sierra Leone TB many people are at risk of developing TB, especially those in
rural and peri- urban areas. The RCH programme will continue to provide BCG
vaccination to children at birth free of cost. The current directly observed treatment
strategy (DOTS) programme mainly focuses on adults with pulmonary TB. The RCH
programme will particularly collaborate with the DOTS programme to ensure that
children benefit from the services and that DOTS is more effective for children.

HIV/AIDS
HIV/AIDS cuts across several of the socio-economic aspects of the country including
social taboos associated with sexual behaviour, drug use, power relationships
between women and men and poverty. Young women in their reproductive age and
who form about half of the country’s population, suffer the brunt of the epidemic. This
in itself poses a threat to the lives of children due to the mother-to-child transmission
of the infection.

The HIV/AIDS programme is planned to prevent the spread of the disease, provide
treatment, care and support to those infected, as well as, mitigate the socio-
economic impact. The programme intends to establish strong collaboration,
coordination, and implementation framework with the RCH for the prevention of
mother-child-transmission (PMTCT), voluntary confidential counselling and testing
(VCCT), promotion of safer blood supply and provision of treatment, care and
support services to all including children, their families and the communities.

SWOT of reproductive and child health services
The following SWOT summarises some of the key challenges in delivering effective
and efficient RCH services. It was done by participants at the MoHS Annual National
Health Review and Planning Workshop, Freetown, November 2007




                                                                                                   26
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008


Table 7. SWOT of reproductive and child health services in Sierra Leone
                   Strengths                                          Weaknesses

-Availability of RCH policies and strategic         - Inadequate number of trained, qualified
plan                                                personnel, especially midwives
- Decentralisation                                  - Insufficient equipment
- Availability of MCH Aides at community            - Frequent modification of reporting tools
level                                               - Poor referral system
- Expansion of MCH training to more districts       - No structure for RCH programme (no
- Strong donor commitment                           directorate)
                                                    - Undefined roles and responsibilities
                                                    - Weak supervision at all levels
                                                    - De-motivated staff
                                                    - Substandard and fake drugs on the market
                                                    - Poor community participation
                                                    - Stock out of essential drugs and supplies

                Opportunities                                            Threats

- Donor support                                     - Difficult terrain
- Political will and commitment                     - Poor road network
- Cooperation with NGOs                             - Continued attrition and migration of health
- Increase in enrolment in schools                  workers
- Presence of consultants for RCH                   - Poor conditions of service
- Presence of committees                            - Inadequate transportation
- Enactment of the child rights and gender          - Harmful traditional practices
bills                                               - Lack of appropriate accommodation
- Existence of community based resources            - Proliferation of quacks
                                                    - High illiteracy rate



2. 4 Key reproductive and child health responsibilities at different levels of
the health system
Effective implementation is facilitated by everyone being clear about who is
responsible for what, at different levels of the health system, as
departments/directorates and as individuals. Box 2 below shows the key RCH
responsibilities at the national, district, basic health facility and community levels. The
MoHS organisational chart is currently being revised. As part of the revision it may
include a new directorate, one for RCH. Once the chart is finalised terms of reference
will be drawn up for each directorate, department and unit and job descriptions
written or revised for individuals.




                                                                                                   27
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008



    Box 2. Key functions in reproductive and child health at different levels of
    the health system

    Central level
    Leadership and governance in reproductive and child health (RCH)
    National RCH policy and strategy
    Contribution to setting national health and disease priorities
    Development of a strategic regulated, accountable, transparent, results based
    RCH programme
    Working on RCH human resource capacity development within the national HRD
    framework
    Ensuring effective referral system
    Relevant RCH information as part of national HIS system
    RCH component of annual planning, monitoring and evaluation cycles
    Setting norms, standards and guidelines in RCH
    Coordination of RCH work within framework of national coordination mechanisms
    Efficient management including supervision of RCH programme

    District level
    RCH inputs to: Assessment of health and management needs
                   : Setting priorities and reviewing progress towards achieving
                   indicators and outputs
                   : Annual district plans
                   : District council and health sector coordination
                   : Ensuring effective referral system
                   : Useful supervision and monitoring
                   : Monthly management work plans
                   : Implementation of user-friendly health services

    Basic health facility level
                 : Implementation of user-friendly RCH health services
                 : Effective and efficient outreach
                 : Supervision
                 : Community participation

    Community level
               : User-friendly, effective and efficient outreach
               : Community participation




                                                                                                   28
  Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
  Plan 2008 -2010, January 2008


  CHAPTER 3.                WHERE DO WE WANT TO BE IN REPRODUCTIVE AND
  CHILD HEALTH?

  In this chapter the MoHS first gives its vision for RCH until 2015 in the form of policy
  goals, objectives, outcomes and guiding principles. The second section of this
  chapter is the key element of this strategic plan. It summarises the direction and
  scope of work in the health sector in the RCH programme for the period 2008 – 2010.
  It helps answer the questions ‘how are we going to successfully achieve the 2007
  reproductive health policy and the 2007 child health policy’? This is done by giving
  the strategic plan goal, objectives, outputs and 8 strategies. The strategies highlight
  what needs to be done and how, within the time frame of this strategic plan. The
  chapter finishes with giving some critical success factors and outlines the main risks
  and assumptions that underpin this RCH strategic plan.

  3.1     Ministry of Health and Sanitation Reproductive Health Policy 2007 - 2015
          and Child Health Policy 2007 – 2015: Goal, objectives, outcomes and
          guiding principles
  The goal of the RCH programme is to make a significant impact on reducing
  maternal and child mortality and morbidity through having a well governed health
  sector and efficient health system with responsive service delivery by stakeholders.
  The goals, objectives and guiding principles in Table 8 have been taken directly from
  the reproductive health and child health policies. The baselines for the outcomes are
  from the 2005 MICS 3. The outcomes in table 7 and the strategic outputs and
  indicators were agreed at stakeholder meetings in the MoHS, December 2007.

  Table 8. Reproductive and child health policies
                         Reproductive health policy                               Child health policy
  Goal           To improve the quality of reproductive and       The Sierra Leone children enjoy the highest
                 sexual health for all Sierra Leonean             attainable standard of health and development
                 people with a bid to reducing poverty and        that meets their needs, and respects, protects
                 achieving the Millennium Development             and fulfils their rights, enabling them to live to
                 Goals particularly those relating to             their full potential and well being
                 reproductive and sexual health
Objectives       -To reduce maternal and neo-natal                -To provide quality obstetric care to all
                 morbidity due to pregnancy and childbirth        pregnancies to ensure the delivery of healthy
                 -To reduce the level of unwanted                 babies and care of the newborn
                 pregnancies in all women of reproductive         -To promote breastfeeding practices within the
                 age                                              first one hour of birth and exclusive
                 -To reduce the incidence and prevalence          breastfeeding for the first five months for all
                 of sexually transmitted infections including     infants
                 HIV and AIDS                                     -To strengthen the immunisation services to
                 -To limit all forms of gender based              cover all children with all antigens
                 violence and other practices that are            -To reduce morbidity and mortality due to ARI in
                 harmful to the health of women and               all children
                 children                                         -To reduce morbidity and mortality due to
                 -To reduce the incidence and prevalence          diarrhoea particularly amongst children and also
                 of reproductive cancers and other non-           reduce any outbreak/epidemics
                 infectious conditions of the reproductive        -To reduce morbidity and mortality due to other
                 health system                                    communicable infectious diseases in all children
                                                                  especially the disadvantaged and those living in
                                                                  hard to reach areas and to increase efforts to
                                                                  prevent congenital malformations in children
                                                                  and render assistance to those affected to seek
                                                                  treatment abroad as necessary
                                                                  -To improve the nutritional status of infants and
                                                                  under-five children




                                                                                                     29
 Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
 Plan 2008 -2010, January 2008


Outcomes        -Maternal mortality ratio reduced from           -Infant mortality rate reduced from 158 to 79
                1,300** to 600                                   -Under-five mortality rate reduced from 267 to
                -Health facility based deliveries increased      95
                from 43% to 75%                                  -Exclusive breastfeeding (0-5 months) rate
                -Contraceptive prevalence increased from         increased from 8% to 75%
                5% to 15%                                        -Fully immunized children (within first 12-24
                -HIV infected positive women who                 months): 90%
                received ARVs to reduce the risk of              --Relevant antibiotic treatment of suspected
                mother-to-child transmission increases           pneumonia increased from 21% to 50%
                from 5% to 60%                                   -Use of oral rehydration therapy (ORT) during
                -Proportion of low birth weight reduced          diarrhoea increased from 60% to 90%
                from 34% to 18%                                  -U5s sleeping under insecticide-treated nets
                                                                 increased from 5% to 80%
                                                                 -Proportion of children with fever receive
                                                                 appropriate treatment within 24 hours increased
                                                                 from 2% to 50%
                                                                 -Underweight prevalence among children under
                                                                 five years of age reduced from 30 % to less
                                                                 than 23%
                                                                 -% of infants born to HIV infected mothers
                                                                 started on relevant prophylaxis within 2 months
                                                                 of age increased from 2% to 60%

 Guiding        -Government ratification of the Convention       -Government ratification of the Convention on
principles      on the Elimination of All Forms of               the Rights of the Child (CRC)
                Discrimination Against Women (CEDAW)             -Equity and respect for human rights
                -The promotion of reproductive rights            -Life cycle approach
                                                                 -A public health approach


 3.2      Strategic direction for RCH 2008 – 2010
 Chapter 1 started by describing what is different and new in the approach to RCH.
 That covers the key aspects of the strategic direction over the next 3 years. The need
 for change has arisen from the sad fact that there have been few marked
 improvements in the health of women and children since 2000. If the quality of life of
 women and children is to improve it cannot be ‘business as usual’. This is what is
 behind the shift towards doing some things differently now as part of our vision of
 where we want to be. Successful businesses in the private sector have some things
 in common with each other. Outstanding leadership, a strategic and action orientated
 culture, very focused on comparative strengths and on priorities and quality,
 creativeness, a client focus and valuing staff being key ones. These success factors
 will be forefront in the institutional development necessary for the success of the
 RCH programme.

 To make an impact both health service implementation and the health
 system/institutional development work need to be undertaken simultaneously, at
 national level institution wide and at district level in all districts. The need for
 simultaneous work, in all districts, means that for health services there will need to be
 a rapid scale up, almost a big bang approach, to implementing the high impact, low
 cost, evidence based interventions. Change management is not amenable to such an
 approach so the institutional/health system changes will more on an incremental
 basis, but should not lag behind.

 Monitoring progress will be undertaken through the MoHS monitoring and evaluation
 (M&E) system. There is no vertical approach to RCH M&E. Using nationally agreed
 indicators and reporting format the intention is to monitor and evaluate progress
 towards successfully achieving the following RCH strategic plan objectives, outputs


                                                                                                    30
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008


and strategies, which can also be seen in annex A of the main strategic plan
document. More detail on this can be found in volume II of this strategic plan. A mid-
term review of this strategic plan will be important followed by a combined evaluation
and planning study towards the end of 2010.

RCH strategic plan goal
To reduce the maternal, under 5 and infant mortality rates by 30% of the 2005 levels
by 2010 by providing comprehensive, quality reproductive and child health services
and strengthening the health system.

RCH strategic plan objectives
  1) Significantly increase the numbers of MCH Aides, SECHNs, and CHOs
  2) Ensure facilities have essential equipment and are functioning efficiently
  3) Increase utilisation of RCH services
  4) Ensure appropriate laws, regulations, rules and guidelines developed and
      enforced
  5) Contribute to more effective monitoring and evaluation
  6) Effective governance and management functions across the health system
  7) Ensure adequate coordination of work at all levels of the health system

RCH strategic plan outputs
It is planned that the following outputs be achieved by the end of the time frame for
this strategic plan, by end 2010. The sum total of the outputs will feed into achieving
the strategic objectives, which in turn will contribute to achieving the policy objectives
and outcomes. The results obtained from the outcomes will contribute to achieving
the health MDGs.
      CHC staffed with a CHO and CHP staffed with a SECHN increases from
         50.8% to 75% and 17.5% to 40% respectively
      17 district hospitals and 70 PHUs providing 24 hour emergency obstetric care
      80% planned outreach from PHUs achieved
      Users perception of quality services increased from % to %
      Reduce stock out of tracer drugs (ACT, amoxycillin and ORS) from 48% to
         10%
      Strategic decentralisation issues addressed1
      Comprehensive specification of cervical routine cervical cancer service
         completed
      Proportion of funds allocated to health increases from 7.9 percent to 15
         percent of total budget and total amount disbursed

RCH programme strategies
The RCH objectives have been turned into the following 8 strategies. Also given are
strategic actions for each strategy. The work is primarily addressed to the national,
central level of the health system but should be adapted where relevant by districts.
Strategies 1, 2 and 5 are all about service delivery and will account for most of the
financial resources needed for RCH implementation. The remaining 5 strategies
mainly address institutional and health systems development and will consume

1
 Address accountability and clarify roles and documents; strengthen coordination and
collaboration; clarify linkages: technical, financial and political; better availability of funds and
more efficient budgeting and accounting systems; make distinctions between governance and
management; clarify functions of hospital boards and consider need for regulation for the
Hospital Boards Act; review functions of district councils in relation to health. Source: MoHS
Annual Review and Planning Workshop, November 2007 (see also decentralisation in section
3.1)



                                                                                                   31
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008


relatively less money, apart maybe from human resource development. All the
strategies should be implemented simultaneously as they are inter-linked and
complementary.

The strategies can also be found in the strategic framework at annex A where it can
be seen that outputs, indicators, key strategic actions and lead responsibility are
given for each strategy. As stated at the beginning of Chapter 1 this national level
strategic plan gives the direction and scope of work in RCH. It therefore should not
go into any more detail. That is up to districts and other cost centres to do in their
annual plans and monthly work plans. Some specific technical subjects such as
malaria and nutrition have policies, strategic plans and/or guidelines which provide
more detail. Also some detail can be found in the RCH operations manual, a
requirement of one of the donors. The list of contents of the manual can be seen at
annex E.

At annex B is the draft outline of the content of the package of essential basic
services which is key to ensuring the integration of RCH into basic health service
delivery. The package may have about 7 components of which the first 4 are directly
relevant to RCH as can be seen in the annex. A list of RCH public health and clinical
interventions at the community, PHU and secondary levels can be found at annex C.
All the interventions/activities listed are high impact, low cost and evidence based
from recent studies published in The Lancet and from Cochrane reviews. A summary
of the cost of the strategic plan is at annex D.

Strategy 1. Effectively implement the reproductive health and child health
components of the package of essential basic services through improving
coverage and utilisation especially at the community level
Necessary strategic actions:
    Rapidly scale up the RCH high impact, low cost, evidence based
       interventions by ensuring adequate support services
    Help develop, including the costing, the package of essential basic services
       and the essential hospital services package
    Ensure all work falls within framework of planned new national health policy
       2008 – 2015 and new national health strategic plan 2008 – 2015 and the 2
       packages mentioned above
    Help ensure 24 hour BEmONC available in relevant health facilities
    Help implement the blood transfusion policy
    Strengthen outreach and referrals through improved communication and
       transport
    Work with others on removing financial and other barriers to accessing health
       services
    Help rationalise location of public and private health facilities
    Help develop IEC/BCC for RCH based on district experience e.g. need for
       changing attitudes and practices
    Ensure effective partnerships implement the services and ensure better
       systems
    Scale up RCH service delivery related initiatives if positive evaluation findings
       (see also strategies 6 and 8)
    Districts to better identify those traditional practitioners with whom a useful
       partnership could be developed
    Help specify a client friendly cervical cancer service




                                                                                                   32
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008


Strategy 2. Improve the quality of reproductive and child health services
through addressing supply and demand issues
Necessary strategic actions:
    Work with other relevant directorates to develop a quality assurance
       programme and a comprehensive programme communication plan
    Raise awareness about, and improve practice of, client orientated RCH
       services among service providers including for safe abortion
    Help districts better identify vulnerable groups and ensure they benefit from
       RCH services
    Finalise and ensure adherence to MoHS RCH standards and norms
    Undertake review of policies where relevant e.g. on abortion
    Develop and implement guidelines and protocols for clinical practice in RCH
       and for referral
    Strengthen the quality of management in PHU facilities to ensure provision of
       efficient health services, focusing in particular on the RCH ones
    Help establish and ensure efficient functioning of a paediatric centre of
       excellence
    Revise list of RCH key knowledge and practices addressed in supervision tool
       and ensure that supervisors have the necessary skills to undertake useful
       supervision
    Ensure client friendly services/activities for responding to, and management
       of victims of gender based violence and also for those with infertility
    Help ensure safe practices e.g. for blood and vaccination safety, safe sharps
       disposal and infection management

Strategy 3. Have the right people in the right place at the right time with the
right skills to deliver RCH services through developing the policy and strategy
context of human resource development, introducing and implementing the
direct midwifery training programme, upgrading the training of SECHNs,
scaling up the intake of current midwifery and MCH aides programme and
helping improve the morale of health workers
Necessary strategic actions:
     Develop and implement new human resource policy
     Develop and implement human resource strategic plan in collaboration with
       Civil Service Commission and other relevant institutions in order to recruit,
       develop and retain staff in the health sector
     Ensure gender mainstreaming in RCH
     Develop and implement a quality framework for all training in collaboration
       with quality team
     Help ensure strong collaboration between MoHS, Ministry of Education and
       health training institutions
     If evaluation findings positive, scale up initiative of TBAs working under direct
       supervision of MCH aides
     Review all curricula to better address RCH issues
     Establish 1-2 more midwifery training facilities at district level
     Train more midwifery tutors
     Develop national plan for both pre-service training and continuing education
       plan and implement RCH components
     Train all doctors, whatever his or her expertise/specialisation, in a district to
       be able to perform an emergency caesarean section

Strategy 4. Achieve results through helping strengthen institutional, systems
and management development at central and local government levels



                                                                                                   33
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008


Necessary strategic actions:
    Help undertake an MoHS institutional review and functional review of district
      councils and help facilitate implementation of relevant findings
    Help develop and ensure functioning of relevant organisational structures at
      different levels of the health system and help ensure all departments, units
      and individuals know their roles and responsibilities through ensuring they
      have terms of reference or job descriptions and understand their civil service
      status
    Help develop and ensure effective functioning of vertical and horizontal health
      system coordination and information sharing
    Encourage the development of transparent decision making mechanisms,
      clear lines of accountability and effective functioning of hospital and other
      boards
    Help maintain effective linkages with other programmes and sectors and
      collaboration with other ministries and key stakeholders
    Ensure effective partnerships to mobilise resources and implement the
      necessary services and systems
    Improve management capacity including knowledge of management culture
      and change management issues
    Review and where necessary develop and/or revise relevant legislation and
      regulations e.g. on abortion and help districts identify relevant, helpful bye
      laws
    Strengthen compliance with laws and regulations and adherence to
      guidelines and protocols
    Strengthen specific health systems e.g. logistics, transport, maintenance,
      communication, procurement, supplies and for accounting
    If contracting in and/or contracting out decided for any (support) service that
      impacts on RCH, help decide contracting principles, elements and systems

Strategy 5. Reduce the RCH related mortality and morbidity of malnutrition,
malaria, HIV/AIDS and TB through working closely with the relevant
programmes to scale up cost effective and high impact interventions
Necessary strategic actions:
    Help raise awareness about relevant IEC/BCC e.g. exclusive breastfeeding
       for the first six months after birth, use of ITNs, safer sex
    Help improve community based coverage of prevention and control
       interventions for HIV, malaria and TB
    Help with the prevention of under-nutrition through interventions focussed
       particularly from pregnancy to 2 years of age e.g. breastfeeding counselling,
       vitamin A supplementation and zinc fortification, also for maternal nutrition
       supplementation with iron, folic acid and other evidence based micronutrients
       and calcium
    Nutritional care of sick and severely malnourished children

Strategy 6. Ensure the planning, monitoring and evaluation of RCH is
integrated within the national systems through contributing to the development
of a robust M&E system and incorporating findings into planning
Necessary strategic actions:
     Facilitate the further development and finalisation of new national health
       policy 2008 – 2015 and national health strategic plan 2008– 2015 so that this
       RCH strategic plan falls within a wider national health vision and direction of
       work
     Develop and implement HIS policy
     Commission relevant surveys and studies


                                                                                                   34
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008


      Undertake evaluation studies, including costs, of RCH
      Institute maternal deaths audit
      Undertake a mid-term review of this strategic plan and a combined
       review/planning exercise towards the end of year 3
    Ensure relevant evaluation and research findings are fed into policy, strategy
       and planning decision making and documents and are disseminated to all
       stakeholders
Strategy 7. Effectively address relevant cross cutting issues through
improved coordination and collaboration mechanisms
Necessary strategic actions:
    Strengthen inter-ministerial and sectoral joint planning on RCH issues
    Improve collaboration with key stakeholders in RCH
    Encourage district councillors to become involved in advocacy on RCH
       issues, especially with members of community
    Encourage development partners working at all levels of the health system to
       follow principle of harmonisation and the RCH programme approach
    Help strengthen community participation
    Ensure advocacy among relevant authorities to improve hygiene, sanitation,
       water supplies and waste management
Strategy 8. Undertake relevant operational research that contributes to RCH
evidence based decision making through commissioning priority studies
Necessary strategic actions:
    Formulate list of priority RCH operational research issues
    Commission research and/or agree on proposals submitted
    Develop research partnership with a Regional academic research centre
    Ensure any operational research results are disseminated and feed into
       policy, planning and other decisions

3.3      The reproductive and child health strategic plan framework 2008 - 2010
There will be at least 2 maybe 3 reproductive and child health strategic plans within
the 8 year time frame of the RCH policies. This is because 8 years is too long for a
national strategy or strategic plan. Internationally, most are for 3 years, maximum 5.
A maximum of 3 years is recommended for post conflict countries because the
context within which health is functioning is usually rapidly changing. As mentioned
earlier the RCH strategic plan framework at annex A gives a comprehensive
snapshot of some of the most important elements in this plan as follows:
      Outcomes have been set for the reproductive and child health objectives that
         will contribute to achieving the MDGs
      The different reproductive and child health policy objectives have been
         consolidated into one reproductive and child health strategic objective to be
         achieved within the 3 year time frame of this strategic plan
      To help achieve the reproductive and child health outcomes, lower level
         strategic planned outputs are given that also aim to contribute to achieving
         the strategic objective.
      To help achieve the strategic objective 8 reproductive and child health
         strategies have been designed as described above
      More pragmatic outputs are given for each of the 8 strategies, these will feed
         into helping achieve the broader strategic planned outputs
      For each of the 8 strategies there are also indicators towards achievement,
         strategic actions and who has lead responsibility for each of the strategies

3.5       Critical success factors, key implications and risks and assumptions

Critical success factors


                                                                                                   35
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008


The critical success factors during implementation of this RCH strategic plan are:
    Strong, sustained political will and commitment
    Effective leadership by the MoHS
    Ownership by all stakeholders and partnerships with donors, agencies, NGOs
        and others
    International donor harmonisation and commitment to providing financial
        resources to implement this strategic plan
    Community participation
    Additional human resources for RCH and their better morale and retention
    Effective and efficient decentralisation
    Removal of barriers to accessing health services

Key implications
The following implications aim only to highlight some important issues that need to be
considered about aspects of RCH.

Implications for:
GoSL
   • Make health, and particularly RCH a ‘high politics’ issue, get it visibly on the
       government’s agenda
   • Act as strong advocate for reduced MMR and U5 mortality rates in particular
       e.g. in parliament, the press, by wives of political VIPs, religious leaders etc
MoHS
    Strong commitment to change
    Be pro-active, risk taker, make sound decisions and stick to them
    Urgent need for RCH lead person to be appointed
Donors
    Provide funds up front not in 6-9 months time, sooner rather than later
    Use variety of mechanisms including budgetary support
    Use GoSL systems to fullest extent possible
    Need for continued commitment to ensuring RCH is part of, and dependent
       on, the wider health system and therefore need to fund work not directly
       related to RCH
Implementers
    Renewed energy and motivation linked to increase in allowances etc
    Need to be open to working differently
    Need to ensure client friendly attitudes and services
Management
    Financial resources - especially recurrent cost implications of scaling up
       services, training, employment, incentives schemes and of any infrastructure
       and equipment
    Human resources - impact on other health cadres of; upgrading training and
       skills of a specific cadre; introducing an incentives scheme for a specific
       cadre
    Other - decentralisation of financial spend; integrated funding mechanism;
       use of GoSL procedures; introduction of any incentives scheme not linked to
       the Civil Service Commission; capacity of management systems e.g. for
       procuring increased amounts of supplies; maintenance for any new
       equipment; enforcement of laws and regulation; monitoring and evaluation
       systems and practices for contracting

Risks and assumptions




                                                                                                   36
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008


In Box 3 are the main risks linked to, and assumptions about, the success of this
RCH strategic plan.
 Box 3. RCH risks and assumptions

 Risks to successful RCH strategic plan implementation:
 Poor macroeconomic growth resulting in no increase in government allocation to the health sector
 Interruption of support for RCH from international agencies as a result of changes in their policies
 or because of political instability
 Literacy levels do not improve and little gender mainstreaming
 Stakeholders do not work within the framework of this RCH strategic plan
 Resistance to change within the MoHS
 Insufficient attention to equity, accessibility, utilisation and quality of care
 Insufficient numbers of women trained as MCH aides and SECHNs in particular
 Slow inclusion of newly trained health staff especially midwives and nurses on national payroll

 Assumptions underlying the RCH strategic plan implementation:
 Continuing stability of the political situation in the country
 Economic growth and continuity of national and international financial resources
 The new government translates its agenda for change especially towards its commitment to good
 governance, sustainable development and braking the cycle of poverty into concrete useful
 actions
 Continued MoHS commitment to change, to reform to respond to changing health system and
 health service needs
 Motivated health staff especially those working on RCH in hard to reach areas
 Strong collaboration between MoHS and health training institutes
 Continuing effective partnerships among stakeholders




                                                                                                   37
                  Annex A. REPRODUCTIVE AND CHILD HEALTH STRATEGIC PLAN FRAMEWORK 2008 – 2010
        Reproductive and child health (RCH) policy objectives                     Reproductive and child health policy outcomes 2007-2015*
                                2007-2015
Reproductive health policy                                                      Reproductive health policy
    To reduce maternal and neo-natal morbidity due to pregnancy and                Maternal mortality ratio reduced from 1,300** to 600
      childbirth                                                                    Health facility based deliveries increased from 43% to 75%
    To reduce the level of unwanted pregnancies in all women of                    Contraceptive prevalence increased from 5% to 15%
      reproductive age                                                              HIV infected positive women who received ARVs to reduce
    To reduce the incidence and prevalence of sexually transmitted                   the risk of mother-to-child transmission increases from 5%
      infections including HIV and AIDS                                               to 60%
    To limit all forms of gender based violence and other practices that           Proportion of low birth weight from 34% to 18%
      are harmful to the health of women and children
    To reduce the incidence and prevalence of reproductive cancers and         Child health policy
      other non-infectious conditions of the reproductive health system              Infant mortality rate reduced from 158 to 79
                                                                                     Under-five mortality rate reduced from 267 to 95
Child health policy                                                                  Exclusive breastfeeding (0-5 months) rate increased from
     To provide quality obstetric care to all pregnancies to ensure the               8% to 40%
       delivery of healthy babies and care of the newborn                            Full immunisation by first birthday increased from 35% to
     To promote breastfeeding practices within the first one hour of birth            80%
       and exclusive breastfeeding for the first five months for all infants         Relevant antibiotic treatment of suspected pneumonia
     To strengthen the immunisation services to cover all children with all           increased from 21% to 50%
       antigens                                                                      Use of oral rehydration therapy (ORT) during diarrhoea
     To reduce morbidity and mortality due to ARI in all children                     increased from 60% to 90%
     To reduce morbidity and mortality due to diarrhoea particularly                U5s sleeping under insecticide-treated nets increased from
       amongst children and also reduce any outbreak/epidemics                         5% to 80%
     To reduce morbidity and mortality due to other communicable                    Proportion of children with fever receive appropriate
       infectious diseases in all children especially the disadvantaged and            treatment within 24 hours increases from 2% to 50%
       those living in hard to reach areas and to increase efforts to prevent        Underweight prevalence among children under five years of
       congenital malformations in children and render assistance to those             age reduced 30 % to less than 23%
       affected to seek treatment abroad as necessary                                % of infants born to HIV infected started on relevant
     To improve the nutritional status of infants and under-five children             prophylaxis within 2 months increased from 2% to 60%
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic Plan 2008 -2010, January 2008




RCH strategic plan: Goal 2008-2010                                                    RCH strategic plan: Planned outputs 2008-2010^

To reduce the maternal, under 5 and infant mortality rates by 30% of the                      CHC staffed with a CHO and CHP staffed with a SECHN
2005 levels by 2010 by providing comprehensive, quality reproductive and                       increases from 50.8% to 75% and 17.5% to 40%
child health services and strengthening the health system.                                     respectively
                                                                                              17 district hospitals and 70 PHUs providing 24 hour
RCH strategic plan: Objective 2008-2010                                                        emergency obstetric care
                                                                                              80% planned outreach from PHUs achieved
1) Significantly increase the numbers of MCH Aides, SECHNs, and CHOs                          Users perception of quality services increased from % to %
2) Ensure facilities have essential equipment and are functioning efficiently                 Reduce stock out of tracer drugs (ACT, amoxycillin and
3) Increase utilisation of RCH services                                                        ORS) from 48% to 10 %
4) Ensure appropriate laws, regulations, rules and guidelines developed and                   Comprehensive specification of cervical routine cervical
enforced                                                                                       cancer service completed
5) Contribute to more effective monitoring and evaluation                                     Strategic decentralisation issues addressed+
6) Effective governance and management functions across the health system                     Proportion of health spend allocated increases and annual
7) Ensure adequate coordination of work that addresses systems wide issues                     expenditure budget disbursed


    RCH strategies                     Strategic actions                Outputs to be achieved         Indicators towards achievement          MoHS lead
                                                                            by end year 3^                for use annually and for mid       responsibility
                                                                                                                  term review^
1. Implement the             1.1 Rapidly scale up the RCH high         - All districts fully           - 30% increase in number of           RCH lead with
reproductive health and      impact, low cost, evidence based          implementing the basic          deliveries by skilled birth           DMOs
child health components      interventions by ensuring adequate        package of basic essential      attendants in each district
of the package of            support services                          services
essential basic services     1.2 Help develop, including the                                           - 20% increase in DPT3/Penta
through improving            costing, the package of essential         - Increase in attendances       coverage in each district
coverage and utilisation     basic services and the essential          for RCH services in health
especially at the            hospital services package                 facilities and the              - 5% increase in early introduction
community level              1.3 Ensure all work falls within          community                       and exclusive breastfeeding
                             framework of planned new national
                             health policy 2008 – 2015 and new
                             national health strategic plan 2008
                             – 2015 and the 2 packages




                                                                                                                                                              39
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic Plan 2008 -2010, January 2008




                             mentioned above
                             1.4 Help ensure 24 hour BEmONC
                             available in relevant health facilities
                             1.5 Help implement the blood
                             transfusion policy
                             1.6 Strengthen outreach and
                             referrals through improved
                             communication and transport
                             1.7 Work with others on removing
                             financial and other barriers to
                             accessing health services
                             1.8 Help rationalise location of
                             public and private health facilities
                             1.9 Help develop IEC/BCC for RCH
                             based on district experience e.g.
                             need for changing attitudes and
                             practices
                             1.10 Ensure effective partnerships
                             implement the services and ensure
                             better systems
                             1.11 Scale up RCH service delivery
                             related initiatives if positive
                             evaluation findings (see also
                             strategies 6 and 8)
                             1.12 Districts to better identify those
                             traditional practitioners with whom a
                             useful partnership could be
                             developed
                             1.13 help specify a comprehensive
                             client friendly cervical cancer
                             service
2. Improve the quality of    2.1 Work with other relevant              - Indications of more           - Increase in % of PHUs reporting   RCH lead with
reproductive and child       directorates to develop a quality         responsive RCH services         uninterrupted supply of tracer      DMOs and
health services through      assurance programme and a                                                 drugs                               district
addressing supply and        comprehensive programme                   - Evidence of more                                                  councils
demand issues                communication plan                        effective RCH health care       - 100% of PHUs with basic tracer




                                                                                                                                                           40
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic Plan 2008 -2010, January 2008




                             2.2 Raise awareness about, and                                            equipment
                             improve practice of, client               - Efficiently run PHUs
                             orientated RCH services among                                             - Evidence of changing attitudes of
                             service providers including for safe                                      staff
                             abortion
                             2.3 Help districts better identify                                        - Each district clearly identified its
                             vulnerable groups and ensure they                                         vulnerable group(s)
                             benefit from RCH services
                             2.4 Finalise and ensure adherence                                         - Evidence that guidelines and
                             to MoHS RCH standards and norms                                           protocols being used
                             2.5 Undertake review of policies
                             where relevant e.g. on abortion                                           - 50% increase in number of PHUs
                             2.6 Develop and implement                                                 supervised quarterly using a
                             guidelines and protocols for clinical                                     nationally approved checklist
                             practice in RCH and for referral
                             2.7 Strengthen the quality of                                             - All village development
                             management in PHU facilities to                                           committees functioning
                             ensure provision of efficient health
                             services, focusing in particular on
                             the RCH ones
                             2.8 Help establish and ensure
                             efficient functioning of a paediatric
                             centre of excellence
                             2.9 Revise list of RCH key
                             knowledge and practices addressed
                             in supervision tool and ensure that
                             supervisors have the necessary
                             skills to undertake useful
                             supervision
                             2.10 Ensure client friendly
                             services/activities for responding to,
                             and management of victims of
                             gender based violence and also for
                             those with infertility
                             2.11 Help ensure safe practices e.g.
                             for blood and vaccination safety,




                                                                                                                                                41
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic Plan 2008 -2010, January 2008




                             safe sharps disposal and infection
                             management

3. Have the right people     3.1 Develop and implement new                -Increase in staff             - 18% increase of staff among             HRD
in the right place at the    human resource policy                        recruitment, retention,        grades 3-14 in each district              Directorate
right time with the right    3.2 Develop and implement human              morale and training                                                      with RCH lead
skills to deliver RCH        resource strategic plan in                                                  - All curricula reviewed for RCH
services through             collaboration with Civil Service             -Increase in number of         content and revised accordingly
developing the policy        Commission and other relevant                female staff in middle and
and strategy context of      institutions in order to recruit,            senior management              - All doctors at district level able to
human resource               develop and retain staff in the              positions                      perform an emergency caesarean
development,                 health sector                                                               section
introducing and              3.3 Ensure gender mainstreaming              - More relevant, theoretical
implementing the direct      in RCH                                       and practical RCH              - Continuing education in RCH in
midwifery training           3.4 Develop and implement a                  components in all curricula    line with national human resource
programme, upgrading         quality framework for all training in                                       continuing education plan
the training of SECHNs,      collaboration with quality team
scaling up the intake of     3.5       Help       ensure         strong
current midwifery and        collaboration       between        MoHS,
MCH aides programme          Ministry of Education and health
and helping improve the      training institutions
morale of health workers     3.6 If evaluation findings positive,
                             scale up initiative of TBAs working
                             under direct supervision of MCH
                             aides
                             3.7 Review all curricula to better
                             address RCH issues
                             3.8 Establish 1-2 more midwifery
                             training facilities at district level
                             3.9 Train more midwifery tutors
                             3.10 Develop national plan for both
                             pre-service training and continuing
                             education plan and implement RCH
                             components
                             3.11Train all doctors, whatever his




                                                                                                                                                                   42
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic Plan 2008 -2010, January 2008




                             or her expertise/specialisation, in a
                             district to be able to perform an
                             emergency caesarean section

4. Achieve results           4.1 Help undertake an MoHS                - Increase in efficiency,       - Institutional review undertaken    Office of the
through helping              institutional review and functional       effectiveness and               and results agreed, accepted and     Minister of
strengthen institutional,    review of district councils and help      accountability of MoHS          implemented                          Health with
systems and                  facilitate implementation of relevant     particularly at central and                                          top and senior
management                   findings                                  district levels                 - Those working on RCH have          management
development at central       4.2 Help develop and ensure                                               relevant ToRs and know their lines
and local government         functioning of relevant                   - All RCH related laws and      of accountability
levels                       organisational structures at different    regulations are appropriate
                             levels of the health system and help      and being enforced
                             ensure all departments, units and
                             individuals know their roles and          - Joint planning and M&E
                             responsibilities through ensuring         between MoHS and
                             they have terms of reference or job       development partners
                             descriptions and understand their
                             civil service status
                             4.3 Help develop and ensure
                             effective functioning of vertical and
                             horizontal health system
                             coordination and information
                             sharing
                             4.4 Encourage the development of
                             transparent decision making
                             mechanisms, clear lines of
                             accountability and effective
                             functioning of hospital and other
                             boards
                             4.5 Help maintain effective linkages
                             with other programmes and sectors
                             and collaboration with other
                             ministries and key stakeholders
                             4.6 Ensure effective partnerships to
                             mobilise resources and implement




                                                                                                                                                             43
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic Plan 2008 -2010, January 2008




                             the necessary services and
                             systems
                             4.7 Improve management capacity
                             including knowledge of
                             management culture and change
                             management issues
                             4.8 Review and where necessary
                             develop and/or revise relevant
                             legislation and regulations e.g. on
                             abortion and help districts identify
                             relevant, helpful bye laws
                             4.9 Strengthen compliance with
                             laws and regulations and
                             adherence to guidelines and
                             protocols
                             4.10 Strengthen specific health
                             systems e.g. logistics, transport,
                             maintenance, communication,
                             procurement, supplies and for
                             accounting
                             4.11 If contracting in and/or
                             contracting out decided for any
                             (support) service that impacts on
                             RCH, help decide contracting
                             principles, elements and systems

5. Reduce the RCH            5.1 Help raise awareness about            - Increase in effective         - 10% decrease in prevalence of       RCH lead
related mortality and        relevant IEC/BCC e.g. exclusive           collaboration between           underweight among children 6-59       person with
morbidity of nutrition,      breastfeeding for the first six           RCH and relevant                months in each district               relevant
malaria, HIV/AIDS and        months after birth, use of ITNs,          programmes                                                            programme
TB through working           safer sex                                                                 - 50% increase in each district of    managers
closely with the relevant    5.2 Help improve community based                                          U5s with fever who received
programmes to scale up       coverage of prevention and control                                        appropriate anti-malarial treatment
cost effective and high      interventions for HIV, malaria and                                        within 24 hours of onset of fever
impact interventions         TB
                             5.3 Help with the prevention of                                           - 100% pregnant women with




                                                                                                                                                           44
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic Plan 2008 -2010, January 2008




                             under-nutrition              through                                      advanced HIV infection receiving
                             interventions focussed particularly                                       antiretroviral combination therapy
                             from pregnancy to 2 years of age                                          in each district
                             e.g.     breastfeeding   counselling,
                             vitamin A supplementation and zinc                                        - Increase to 85% of smear-
                             fortification, also for maternal                                          positive pulmonary TB cases
                             nutrition supplementation with iron,                                      treated successfully
                             folic acid and other evidence based                                       -
                             micronutrients and calcium
                             5.4 Nutritional care of sick and
                             severely malnourished children

6. Ensure the planning,      6.1 Facilitate the further                - RCH is an integral part of    - New national health policy,         Health
monitoring and               development and finalisation of new       the national health system      national strategic plan and HIS       Planning and
evaluation of RCH is         national health policy 2008 – 2015                                        policy developed and being            Information
integrated within the        and national health strategic plan                                        implemented                           Directorate
national systems through     2008– 2015 so that this RCH
contributing to the          strategic plan falls within a wider                                       - 100% increase in all districts in
development of a robust      national health vision and direction                                      monthly ICS reports submitted on
M&E system and               of work                                                                   time by PHUs to districts
incorporating findings       6.2 Develop and implement HIS
into planning                policy                                                                    - Relevant surveys and studies
                             6.3 Commission relevant surveys                                           undertaken and results
                             and studies                                                               disseminated and being used for
                             6.4 Undertake evaluation studies,                                         evidence based decision making
                             including costs, of RCH
                             6.5 Institute maternal deaths audit                                       - Mid term review process planned
                             6.6 Undertake a mid-term review of                                        and undertaken and ToR
                             this strategic plan and a combined                                        developed for evaluation/planning
                             review/planning exercise towards                                          study
                             the end of year 3
                             6.7 Ensure relevant evaluation and
                             research findings are fed into policy,
                             strategy and planning decision
                             making and documents and are
                             disseminated to all stakeholders




                                                                                                                                                            45
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic Plan 2008 -2010, January 2008




7. Effectively address       7.1 Strengthen inter-ministerial and      - Greater synergy between       - Evidence of regular monthly        Office of the
relevant cross cutting       sectoral joint planning on RCH            RCH and cross cutting           district management teams in all     Chief Medical
issues through improved      issues                                    issues                          districts                            Officer
coordination and             7.2 Improve collaboration with key
collaboration                stakeholders in RCH                                                       - 75 % increase in number of
mechanisms                   7.3 Encourage district councillors to                                     districts which organised at least
                             become involved in advocacy on                                            one review meeting each quarter
                             RCH issues, especially with
                             members of community                                                      - Further evidence of increasing
                             7.4 Encourage development                                                 donor support and harmonisation
                             partners working at all levels of the
                             health system to follow principle of                                      - Communities actively
                             harmonisation and the RCH                                                 participating in village
                             programme approach                                                        development committees
                             7.5 Help strengthen community
                             participation
                             7.6 Ensure advocacy among
                             relevant authorities to improve
                             hygiene, sanitation, water supplies
                             and waste management
8. Undertake relevant        8.1 Formulate list of priority RCH        - Increase in number of         - List of priority RCH research      RCH lead
operational research that    operational research issues               RCH evidence based              produced annually and reflects       with Health
contributes to RCH           8.2 Commission research and/or            interventions                   key issues/bottlenecks               Planning and
evidence based decision      agree on proposals submitted                                                                                   Information
making through               8.3 Develop research partnership          - Sound information on          - MoHS Planning and Information      Directorate
commissioning priority       with a Regional academic research         how best to remove              Directorate commissions and
studies                      centre                                    barriers to accessing RCH       oversees research, ensures
                             8.4 Ensure any operational                health services                 ministry approval on findings and
                             research results are disseminated                                         disseminates results
                             and feed into policy, planning and
                             other decisions


Most baseline data (apart from MMR) from Sierra Leone Multiple Indicator Cluster Survey (MICS3) 2005, Statistics Sierra Leone and UNICEF, March 2007
** MICS 3 adjusted MMR, UNICEF et al 2007




                                                                                                                                                            46
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic Plan 2008 -2010, January 2008




^ Baselines, outcomes, outputs and indicators agreed at stakeholder meetings, December 2007. The outputs are lower level ones and therefore quantitative
targets are not given for either them or the indicators. The sum total of the outputs should help achieve the 8 planned outputs
+ Address accountability and clarify roles and documents; strengthen coordination and collaboration; clarify linkages: technical, financial and political; better
availability of funds and more efficient budgeting and accounting systems; make distinctions between governance and management; clarify functions of
hospital boards and consider need for regulation for the Hospital Boards Act; review functions of district councils. Source: MoHS Annual Review and Planning
Workshop, November 2007 (see also decentralisation in section 3.1)




                                                                                                                                                              47
Annex B:       Draft outline of content of package of basic essential health
services


Work started on developing the package of basic essential service towards the end
of November 2007. It is anticipated that the design and costing of the package will be
finalised by mid 2008.

Within the package of basic essential services it is anticipated that mention will be
made to both the actual basic health services and the crucial support services and
systems.

Health services
Maternal and new born health e.g. including antenatal, delivery and postpartum care
including emergency caesarean; family planning, care of the newborn


Child health e.g. including EPI; IMCI; breast feeding, school health


Nutrition e.g. exclusive breastfeeding, complementary feeding with continued breastfeeding,
vitamin A supplementation and zinc fortification, also for maternal nutrition supplementation
with iron, folic acid and other evidence based micronutrients and calcium, nutritional care of
sick and severely malnourished children,

Communicable diseases e.g. prevention and control of TB, malaria and HIV/AIDS


Chronic diseases -

Mental health -

Disability -


?Cataract
Support services
Essential drugs and equipment
What other?
ANNEX C: PUBLIC HEALTH AND CLINICAL INTERVENTIONS IN REPRODUCTIVE AND CHILD HEALTH SERVICES*

    Sub                 Family/community based               PHU level including population based outreach                 Secondary hospital
 programme                                                                      services
    area
ANC              Pregnancy registration                    3 checkups including urine test and BP                  Management of referred cases
                 IEC/BCC on danger signs of pregnancy      Screening for risk pregnancies                          Treatment of eclampsia
                 Motivating pregnant women for ANC on      TT                                                      Treatment of complicated cases/
                  awareness for institutional deliveries    De-worming                                               toxaemias
                 Supervision of TBAs                       Provide calcium supplementation
                 Promotion of Family Planning (FP)         ITN
                  services
                                                            RTI/STI screening
                 Supply condoms and other
                  contraceptives                            Malaria screening
                 Promote early and exclusive breast        Anaemia screening and treatment of anaemia with
                  feeding                                    iron supplementation
                 WASH                                      IPT
                 IEC/BCC on harmful traditional            Screening, initiate treatment and referral for
                  practices                                  eclampsia
                                                            Treatment and follow-up of pre-eclampsia
                                                            Detection and treatment of asymptomatic bacteriuria
                                                            Detection and management of syphilis
                                                            PMTCT
                                                            Facility to do pregnancy tests
Delivery care    TBA training for referral                 Supervision of TBAs                                     CEOC including CS
                 Referral services                         Clean delivery and cord care                            Blood transfusion
                 Community transportation                  Normal institutional delivery
                 Awareness of clean delivery and cord      Referral for HR pregnancy
                  care                                      BEMOC
                 Distribution of vouchers for free         Promote early initiation of breastfeeding within one
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic Plan 2008 -2010, January 2008




      Sub                    Family/community based                      PHU level including population based outreach                     Secondary hospital
   programme                                                                                services
      area
                       services                                          hour and continue exclusive breastfeeding for six
                      Registration of birth                             months
                                                                      Registration of birth
                                                                      ?Record birth weight on growth card
                                                                              PMTCT
 Post natal care      Ensure 3 visits, 1st day, 2nd and 7th          Care of neonates by MCH Aides                                Referral services for
                       day by family/TBA                              Provision of outreach kit with equipments, supplies,          complications, contraceptive
                      Counselling to promote early and                bag and mask to MCH Aides                                     services, IUD insertion
                       exclusive breast feeding                       Strengthening of immunisation, contraceptive                 Computerisation of linked mother
                      Monitoring of implementation by VDC?            services. IEC, BCC                                            child cards at block level for case
                                                                                                                                     monitoring of outcomes
                      Identify volunteer couples in each             Establish mother child linked card and issue during
                       village to distribute birth spacing             ANC                                                          Tubal ligation
                       commodities                                    All MCH Aides trained and supervised on semi-
                      IEC/BCC to promote permanent                    permanent methods of contraception and proper
                       methods by TBAs                                 asepsis
                      Innovative methods of social marketing         Referral services for complications
                       of contraceptives                              ?Post-partum VIT A supplementation (within 6
                      Distribution of vitamin A by TBAs and           weeks)
                       other CHV
 Safe abortion        Raise awareness about unsafe abortion          Initial management and refer                                 Conservative treatment and D&C
                                                                      Conservative treatment and D&C of threatened                  of threatened abortion
                                                                       abortion                                                     Management of unsafe abortion
                                                                      Availability of MVA                                          Availability of MVA and medical
                                                                                                                                     abortion services
                                                                                                                                    Advocacy to review legislation on
                                                                                                                                     abortion
 Other                Organise transport for patient with            Screening and referral of obstetric fistula                  Management of cases of
 obstetric and         ruptured ectopic pregnancy, prolapsed                                                                         prolapsed uterus, DUB, cervical




                                                                                                                                                                      50
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic Plan 2008 -2010, January 2008




       Sub                   Family/community based                      PHU level including population based outreach                      Secondary hospital
    programme                                                                               services
       area
 gynaecologica         uterus, DUB, cervical erosion, inversion       Initial management and arrange referral for ectopic             erosion, inversion and rupture
 l conditions          and ruptured uterus                             pregnancy                                                       uterus
                      IEC/BCC on rape and other violence             Organise referral for prolapsed uterus, DUB,                 Laparatomy for management of
                       against women                                   cervical erosion, inversion and rupture uterus                ectopic pregnancy
                      IEC/BCC on obstetric fistula                   Treatment and refer ectopic pregnancy                        Diagnosis and management of
                                                                      Treatment and referral of menstrual irregularities            menstrual irregularities
                                                                      Initial management and referral of cases of                  Diagnosis and management of
                                                                       prolapsed uterus, DUB, cervical erosion, inversion            prolapsed uterus, DUB, cervical
                                                                       and rupture uterus                                            erosion, inversion and rupture
                                                                                                                                     uterus
                                                                      Assess and referral of infertility
                                                                                                                                    Treatment and referral of infertility
                                                                      Treatment of rape and referral services
                                                                                                                                    Treatment of obstetric fistula
                                                                              Treatment and referral of obstetric fistula

 Other                IEC/BCC on cervical cancer, rape,                     IEC/BCC on cervical cancer, rape, gender              Undertake relevant examinations
 reproductive          gender based violence and infertility             based violence and infertility                              and treatments
 and sexual                                                                   Counselling for rape and gender based
 health issues                                                           violence victims and treatment of any injuries
                                                                              Refer patients with possible cervical cancer
                                                                         and for possible infertility
 Adolescent           Conduct IEC/BCC on delaying                    Provision of condoms/OCPs and information on                 Once a week: adolescent clinic at
 health                marriage, fertility awareness, menstrual        Emergency contraception                                       PHC
                       hygiene, care during pregnancy                 Risk reduction counselling for prevention of STI             Routine out-patient services
                      Nutrition education                           For Girls
                      Awareness on gender relations and role         Contraceptive services for delaying pregnancy
                       of men                                         ANC for pregnant adolescents
                      IEC/BCC on traditional practices and           Referrals for ECPs
                       their harmful affect
                                                                      Advise for institutional delivery for primigravidas




                                                                                                                                                                        51
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic Plan 2008 -2010, January 2008




      Sub                    Family/community based                    PHU level including population based outreach                     Secondary hospital
   programme                                                                              services
      area
                      Counselling of newly married                   Services for prevention and management of
                       adolescents                                     nutritional anaemia
                                                                      Counselling on menstrual problems
                                                                      Syndromic management of STIs and referral
                                                                      Referrals for unwanted pregnancy
                                                                     For Boys
                                                                      Provision of condoms and information on EC
                                                                      Group counselling on myths and misconceptions on
                                                                       sex related issues and problems
                                                                      Risk reduction counselling
                                                                      Syndromic management of STIs and referral
                                                                       services
                                                                      Multi purpose Health check-up camps for identifying
                                                                       disabilities and chronic problems. Referrals to
                                                                       district hospitals for remedial measures
                                                                      Once a week: adolescent clinic for both sexes will
                                                                       be organised at PHU for 2 hrs.
 Contraceptive        Organising depot holders (shops, BFV)          Provision of IUDs and other semi-permanent
 and family            for social marketing of contraceptives          methods
 planning                                                             Counselling on contraception to eligible couples
 services
                                                                      Availability and distribution of oral contraceptives
                                                                       and condoms

     Sub                     Family/community based                    PHU level including population based outreach                    Secondary hospitals
  programme                                                                               services
     area
Neonatal care         Awareness on new born care:                    Resuscitation of new born babies, manage and                Manage in special care nursery
                       -Cord care                                      refer if needed                                              for:




                                                                                                                                                                 52
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic Plan 2008 -2010, January 2008




     Sub                     Family/community based                    PHU level including population based outreach                     Secondary hospitals
  programme                                                                               services
     area
                       -Extra care of the low birth weight            Treatment of low birth weight babies                           -Resuscitation of new born
                     babies                                           Resuscitate and refer all babies born weighing less            babies and manage
                      Resuscitation of new born babies and            than 1.8kg                                                    -Manage premature babies
                        refer by families and TBAs                    Resuscitate and refer all premature babies                    -Investigate and treat all neonatal
                      IEC/BCC for early and exclusive                Treatment and referral of septicaemia cases of             jaundice
                        breastfeeding                                  neonates                                                    Management and referral
                      Provide community-based                        Referral services for neonatal tetanus and                     services for congenital defects
                        management of neonatal pneumonia               congenital defects                                          Management of neonatal tetanus
                        by TBA/BFV
IMNCI                 Home visits of neonates by MCH                 Full immunization                                           Diagnosis for rota virus and
                        Aides/TBAs on days 0, 1,2 and 7 and           Vitamin A treatment for measles                              bloody dysentery with rapid
                        thereafter weekly focusing:                                                                                 diagnostic kits
                                                                      Vitamin A supplementation and additional measles
                              -Weighing of neonates in 24 hrs          vaccine for severely malnourished through feeding           Emergency care of ARI
                              -Birth registration                      centres                                                     Care of newborn and referred
                              -High risk screening                    Antibiotics for ARI and dysentery                            neonates as per IMNCI protocol
                      Vitamin A for all children (6 - 59             Follow-up visits for low birth weight babies
                        months)                                       Referral of high risk children
                      ACT for malaria                                Lactation management for prevention and
                      Community based growth monitoring               management of mothers and child complications
                      HE of community in identification of           Establish system for referral and monitoring on
                        high risk new born                             danger signals of LRTIs and pneumonia
                      Involve local communities like TBAs            Piloting computerisation of linked mother child
                        BFV, local & NGOS in mobilizing for             cards at chiefdom level for case monitoring of
                        immunization                                    outcomes
                      Educating families on diarrhoea                 Care of newborn and referred neonates
                        management and more local groups in            Provision of IMNCI as per protocol (including
                        distribution of ORS                             management of severe dehydration
                      De-worming with Albendazole
                      ?Hold durbars to discuss health issues




                                                                                                                                                                     53
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic Plan 2008 -2010, January 2008




       Sub                   Family/community based                    PHU level including population based outreach                   Secondary hospitals
  programme                                                                               services
       area
Infant and child      IEC/BCC for exclusive breastfeeding     Organise supplementary feeding and therapeutic
nutrition              for children 0-5 months and              feeding for malnourished children
                       breastfeeding + complimentary
                       feeding up to 1 year
                      Distribution of vitamin A by TBAs
                      Organise supplementary/therapeutic
                       feeding for malnourished children
Immunization           IEC and social mobilization for       Conduct immunisation sessions
                         immunisation.                        Data on immunization collected and aggregated at
                       Involve VDC, NGOs, adolescent girls    PHU level (coverage disaggregated by gender,
                         and youth clubs, teachers and         social status etc.)
                         students in the social mobilization  Cold chain management and immunization
                         campaigns.
                                                              Transport to outreach areas
*All the interventions/activities listed are high impact, low cost and evidence based from recent studies reported in The Lancet and from
Cochrane reviews




                                                                                                                                                             54
ANNEX D:   SUMMARY OF COST OF REPRODUCTIVE AND CHILD HEALTH
           STRATEGIC PLAN
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008



ANNEX E:         CONTENTS PAGE OF THE REPRODUCTIVE AND CHILD
                 HEALTH OPERATIONS MANUAL
                                        Table of Contents

    Table of Contents
       List of Tables and Annexes
       Acronyms

    1. The Reproductive and Child Health Programme (RCHP)
       1.1   Programme Strategic Plan, Goals and Objectives
       1.2   Human Resource Policy and HR Development Planning
       1.3   Sources of Support
             1.3.1 Government of Sierra Leone
             1.3.2 World Bank
             1.3.3 U.K. Department for International Development
             1.3.4 Irish Aid
             1.3.5 UNICEF
             1.3.6 World Health Organisation

    2. Government Institutional Framework, Roles and Tasks
       2.1   Institutional Framework
       2.2   Ministry of Health and Sanitation (MoHS)
             2.2.1 Central Level
             2.2.2 Local Level
       2.3   Ministry of Local Government and Community Development
       2.4   Institutional Reform and Capacity Building Project
       2.5   Ministry of Finance and the Local Government Finance Department
       2.6   Ministry of Education, Science and Technology
       2.7   Ministry of Social Welfare, Gender and Children’s Affairs
       2.8   Local Councils (District and Town Councils)
       2.9   Civil Society (NGOs and Private Sector)
       2.10  Coordination among development partners

    3. Implementation Plan and Arrangements
       3.1   Implementation Plan for Reproductive and Adolescent Health, Child Health
             and Survival and Support Services to the Basic Package
       3.2   Implementation Plan for RCHP - Environmental Protection
       3.3   Implementation Plan for Technical Assistance
       3.4   Implementation Plan for Procurement 2008
       3.5   Implementation Arrangements and Key Staff

    4. Human Resource Development
       4.1   Human Resource Plan and Policies
       4.2   Human Resource Development Procedures
       4.3   Health Education Launching Programme (HELP!)

    5. Gender Equity Policies and Procedures

    6. Financial Management
       6.1    Financial Management Procedures
       6.2    Financial Management Reporting
       6.3    External Audit
       6.4    Designated Accounts and Funds Flow
       6.5    Disbursement Procedures
       6.6    Special Accounts Procedures
       6.7    Filing and Record Keeping
       6.8    Financial Reporting
       6.9    Internal Control and External Audit


                                                                                                   56
Government of Sierra Leone, Ministry of Health and Sanitation, Reproductive and Child Health Strategic
Plan 2008 -2010, January 2008



    7. Procurement
       7.1    General Principles
       7.2    Procurement Planning
       7.3    Procurement Authority and Management
       7.4    The Procurement Unit
       7.5    The Procurement Committee
       7.6    Procurement Categories
       7.7    Procurement Procedures
              7.7.1 Procurement methods for goods and works
              7.7.2 Procurement of Services
              7.7.3 Sale of Bid Documents
              7.7.4 Bid Opening Procedure
              7.7.5 Bid Evaluation and Approval
              7.7.6 Detailed Evaluation of Bids for Works
              7.7.7 Post evaluation considerations
              7.7.8 Contract Administration
              7.7.9 Procurement Audits and Reports

    8. Monitoring and Evaluation (M&E) for Performance Improvement
       8.1    M&E Performance Plan and Objectives
       8.2    The Strategic Plan and the Implementation Plan for Strengthening the Health
              Information System (HIS)
       8.3    M&E Structure at the Central Level
       8.4    M&E Structure at the Local Level and the LGFD
       8.5    Central-Local M&E Coordination
       8.6    Data Collection Methods, Analysis, Reporting and Feedback
       8.7    Strengthening Data Management
       8.8    M&E Capacity Building
       8.9    Data Products and Dissemination
       8.10   Annual Programme Review

    9. Reporting Requirements

    10. Civil Society Participation
        10.1    Local Councils – Civil Society Relationship
        10.2    Types of Civil Society Engagement
        10.3    Eligibility Criteria
        10.4    Project Preparation and Appraisal Procedures
        10.5    Selection Criteria
        10.6    Contracting
        10.7    Disbursement and Financial Control




                                                                                                   57