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Comprehensive Analytical Profile: Sierra Leone

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This analytical profile provides a health situation analysis of the Sierra Leone and, coupled with the Factsheet, it is the most significant output of the African Health Observatory. The profile is structured in such a way to be as comprehensive as possible. It is systematically arranged under eight major headings:
1. Introduction to country context
2. Health status and trends
3. Progress on the Health-Related MDGs
4. The Health System
5. Specific Programmes and Services
6. Key Determinants
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Statistical profile
Introduction to Country Context

The Republic of Sierra Leone is one of the 54 countries of Africa. It is situated on the west coast and shares borders with Guinea and Liberia. The country’s total surface area is about 72 000 km2. Its 400 km coastline overlooks the north Atlantic Ocean.

Sierra Leone has an estimated population of 5.9 million, 37% of which reside in urban areas.[1] The average annual growth rate is about 2%. However, the population is experiencing significant rural to urban migration, leading to an estimated urbanization rate of 2.9%.[1]

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The female population accounts for 52% of the total population and the average total fertility rate is 5.1 children per woman.[1] Women of the reproductive age group 15–49 years constitute approximately 25% of the population. Adolescents and young people represent about 55% of the population. Infants and children aged under 5 years constitute 4% and 16%, respectively.

The adult literacy rate is estimated at 27% for women and 45% for men. There are about 20 distinct language groups in Sierra Leone, reflecting the diversity of cultural traditions.

Health Status and Trends

The health status of the people of Sierra Leone is still among the worst in the world. Infant and maternal mortality rates remain among the highest in the world. According to the Sierra Leone demographic health survey 2008, life expectancy is 47 years, infant mortality rate is 89 per 1000 live births, under-five mortality rate is 140 per 1000 live births and maternal mortality ratio is 857 per 100 000 births.[1] Fertility rates are high due to low contraceptive prevalence rates.[2]

The most recent United Nations Children’s Fund/WHO estimate for child mortality assumes considerable underreporting in the Sierra Leone demographic health survey 2008 and puts the under-five mortality rate figure at 192 per 1000 live births for 2009.[3] Thus it seems that the indicators for maternal and child mortality for Sierra Leone are in a state of flux and should be reviewed more stringently. However, whichever way they are viewed, the indicators put Sierra Leone among the highest mortality rate countries in the world.

Progress
Progress on SDGs
The Health System
Health system outcomes

The Government of Sierra Leone, in consultation with partners, has developed a 6-year National Health Sector Strategic Plan, which provides the framework for improving the health of the nation.[2]

For sustainability in the implementation of the National Health Sector Strategic Plan, the Government and health partners developed and recently signed a compact agreement, with the objective to set out a framework to guide all health partners working in Sierra Leone adhere to the principles and approaches set out in the International Health Partnership Global Compact Agreement, which reflects the goals of the Paris Declaration.

Leadership and governance

The Ministry of Health and Sanitation is the statutory body responsible for coordinating health interventions and actions in Sierra Leone. The Ministry has made several provisions to influence the overall policy framework in the country.[2][4]

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In collaboration with development partners, the Ministry developed the Joint Programme of Work and Funding to operate the National Health Sector Strategic Plan in a more coordinated and effective manner by outlining the priority health interventions to be implemented over the period 2012–2014, their resource implications and financing situation.[5]

Recently, the Ministry and its partners signed a compact agreement for better coordination of the health sector.[6]

Community ownership and participation

In Sierra Leone, the focus for people’s participation in the planning, implementation and monitoring of health care delivery is through community development committees and subcommittees, for example the health subcommittee and other community-based organizations such as the district AIDS committee, etc.

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There are enormous potential benefits for enhancing the livelihoods of the rural poor through decentralization and through effective representation and accountability, which can be achieved through a parallel process of community-based activities led by civil society and other informal structures such as women’s clubs and complemented by institutional reforms.[7][8]

At district and national levels there are encouraging examples of civil society participation in the health sector. Civil society supports the implementation of the recently signed compact agreement and the Joint Programme of Work Fund, especially in the areas of advocacy and effective monitoring.

Partnerships for health development

Following the review of the National Health Policy in 2009, the Government of Sierra Leone, in consultation with partners, developed the National Health Sector Strategic Plan to provide the framework for improving the health of the nation.[2] The implementation of this Plan requires concerted effort from all stakeholders in the health sector. Consequently, the Sierra Leone compact agreement was developed to ensure sustainability of funding and coordination within the health sector.[6]

This compact agreement sets out understandings reached between the Government and the health partners who are signatories to it. The main objective is to set out a framework for increased and more effective aid to permit Sierra Leone to make faster progress towards achieving the goals of the Agenda for Change and the health-related Millennium Development Goals.

Health information, research, evidence and knowledge

There has been some progress on the health information management system. Reporting completeness has increased from 74% in 2009 to 83% in 2010. However, the good progress of the implementation and strengthening of the health management information system has been weakened by the non-existence of a functional interoperable human resources for health, health financial management and health logistics management information systems. Furthermore, the use of information for decision-making has not been widespread within the sector.

Health financing system

The Ministry of Health and Sanitation designed the Sierra Leone National Health Sector Strategic Plan, which consists of six main pillars through which to deliver and finance health care.

Consequently, funding is requested from the consolidated fund and development partners.[2] The health sector is substantially dependent on external resources for funding. The estimated cost to implement the Free Health Care Initiative policy in 2010 was US$ 35 840 173, of which 86.5% was provided by partners, mainly the Asian Development Bank, Department for International Development (United Kingdom), United Nations Children’s Fund, United Nations Population Fund and World Bank (see tables).[9]

Service delivery

Health service delivery remains a challenge in post-war Sierra Leone. The 10-year war, which ended in 2002, seriously damaged the health system. This situation continues to undermine standards, availability and accessibility of services provided. The country’s health service delivery system is pluralistic: Government, religious missions, local and international nongovernmental organizations and the private sector all provide services. There are public, private for-profit, private non-profit and traditional medicine practices.

The private sector is underdeveloped compared with other countries in the subregion such as Ghana and involves mainly curative care for inpatients and outpatients on a fee-for-service basis. Private health facilities operate under the authority of individual owners and/or boards of directors, mainly in urban areas. The non-poor tend to use private health facilities more often than the poor.

Health workforce

In Sierra Leone, the public health sector’s human resources for health is led by the Ministry of Health and Sanitation’s Human Resources for Health Department. This department is headed by a qualified and experienced Director who reports directly to the Permanent Secretary. However, there is limited internal capacity to manage human resources for health as a strategic function of the Ministry.[10] Only six of the department's strategic objectives were partially achieved.

With support from WHO, the Ministry’s Human Resources for Health Policy is being reviewed to pave the way for the development of a strategic plan, training plan and human resources for health observatory for planning, management and evaluation. Following the introduction of the Free Health Care Initiative, salaries of health workers in the Ministry have considerably improved. A performance-based funding system has also been introduced to motivate health workers, especially in hard to reach areas.

Medical products, vaccines, infrastructures and equipment

With regard to access to affordable medical products and health technologies, there has been a huge investment in drug and medical products procurement with over US$ 13 million spent by donors on procuring drugs and medical products for the Free Health Care Initiative. The Government of Sierra Leone has spent billions of leones more on the procurement of cost recovery drugs.

Despite this large investment, the recent service availability and assessment report shows that, on average, facilities had only about 35% of the required essential drugs in stock.[11] Some progress was made in reviewing the essential drugs and consumables lists for 2010, which ensured the availability of quality and medical consumables and equipment in health facilities.

General country health policies

Various health sector policies have been developed over the years:[1]

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Universal coverage

Universal coverage aims to achieve population coverage through universal pooled funding. This is an important objective of most health systems and requires provision of comprehensive preventive and curative care, free at point of delivery to the entire population. This definition implies two dimensions of coverage: breadth and depth.

Breadth refers to the proportion of the population receiving access to the package. Depth refers to the extent of the services that are covered. In almost all societies, even those that are considered wealthy, there is some trade-off between breadth and depth.

At this stage of development, universal coverage for a comprehensive package of services for the majority of the population of Sierra Leone is not achievable. However, other initiatives exist towards universal coverage.

Specific Programmes and Services
HIV/AIDS

A 2005 national population-based seroprevalence survey for HIV reported a national prevalence of 1.53%.[12] The Sierra Leone health and demographic survey, 2008 found that 1.7% of women and 1.2% of men were HIV positive, with an overall prevalence of 1.5%.[1]

However, in spite of the low HIV prevalence rate there are predisposing factors for increased HIV infection, such as the high prevalence of sexually transmitted infections and ignorance; only 17.2% of young females and 27.6% of young males have comprehensive knowledge about HIV prevention. During the Sierra Leone Health and Demographic Survey 2008, it was found that only 13% of women and 8% of men aged 15–49 years, respectively, had had an HIV test in the past 12 months.[12]

Tuberculosis

One of the priorities of the Ministry of Health and Sanitation is the control of tuberculosis (TB). With an estimated prevalence of 574 cases per 100 000 population and new smear-positive cases of 247 per 100 000 population, the burden of TB is increasing in Sierra Leone.

TB trend in Sierra Leone, 2004–2007[13]

The number of registered TB cases in the country almost doubled between 2004 and 2007. The case detection rate increased from 42% in 2004 to 52% in 2007 (the WHO target is 75%) (see table).[13]

TB treatment success rate increased from 79% in 2000 to 84% in 2005, and then to 86% in 2009, but reduced to 79% in 2010.[3]

Malaria

Malaria is one of the most serious public health problems in Sierra Leone. It is the most common cause of illness and death in the country, accounting for about 50% of outpatient visits and 38% of admissions. Malaria-related illnesses contribute to 38% and 25% of child and all-ages mortality rates, respectively. The most vulnerable groups include children aged under 5 years and pregnant women.[1]

The 2011 Sierra Leone service availability and readiness assessment[14] reported that over 24% of children aged under 5 years had malaria in the 2 weeks preceding the survey and that 26% of children aged under 5 years and 27% of pregnant women slept under insecticide-treated nets. The survey also reported that only 15% of children with fever received antimalarial medicines within 24 hours of onset of symptoms and less than 2% of children under 5 years received drugs within 24 hours.[14]

Immunization and vaccines development

In the late 1960s, Sierra Leone was part of the West Africa Smallpox Eradication Programme. Mobile teams from the Ministry of Health’s Endemic Disease Control Unit carried out the vaccinations and the last recorded small pox outbreak was in April 1969.

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In 1978, the Ministry of Health, in collaboration with the United Nations Children’s Fund, United States Agency for International Development, WHO and funds from the Italian Government, established the Expanded Programme on Immunization as an intervention programme to reduce the very high infant mortality rate in Sierra Leone.[15]

From 1978 to 1986, immunization coverage was just 6%. It increased marginally to 24% in 1989 but to achieve a better coverage there was a need to restructure the programme management. Accordingly, with the support of the United Nations Children’s Fund, the Expanded Programme of Immunization was integrated into existing maternal and child health services to constitute the Integrated Maternal and Child Health Programme.

Child and adolescent health
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Sierra Leone is ranked as having the highest under-five mortality rate in the world, with almost one out of every three children dying before the age of 5 years.[16]

A notable characteristic of under-five mortality in Sierra Leone is that urban–rural differences are very small; in the Sierra Leone health and demographic survey 2008[1] the figures were 167 and 168 deaths per 1000 live births, respectively.

Urban–rural differences in infant mortality are also very small. However, differences by wealth quintile are large, with the poorest quintile having a child mortality rate 150% higher than the best-off quintile.[1]

Maternal and newborn health

In addition to its high child mortality rate, Sierra Leone has one of the highest maternal mortality rates in the world, with a maternal mortality ratio of 857 per 100 000 live births.[3]

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The Sierra Leone Health and Demographic Survey 2008 reported that 87% of pregnant women had attended antenatal care at least once, only 25% of births were institutional deliveries and 43% were supervised by skilled attendants.[1]

This is a surprising result and can only be true if a significant number were attended at home by professionals. The health management information system cannot provide such data.[3] However, approximately 73% of births occurred in rural areas and many of these institutional deliveries were attended by maternal and child health aides who lack the competencies to qualify as skilled attendants.[3]

Gender and women's health

Females constitute about 51% of the population of Sierra Leone. Most live in rural areas and are engaged in subsistence farming, petty trading and family management. Over the years, the Government of Sierra Leone has endeavoured to ensure that its programmes address gender issues and tap women’s potential to move into the mainstream of the country’s development.

Following the United Nations Fourth World Conference on Women in Beijing in 1995, and in recognition of the contribution of women to the development of Sierra Leone, the Government established the Ministry of Social Welfare, Gender and Children’s Affairs in 1996. This signalled a novel and significant commitment by the Government to address gender issues at the highest level, a move that gave encouragement to women.

Epidemic and pandemic-prone diseases

In 2004, Sierra Leone adopted the Integrated Disease Surveillance and Response as a strategy to streamline and improve data collection, reporting and analysis from previously disparate disease-reporting systems in the country.

The list of priority communicable diseases was reviewed and increased to 22 in 2007 and training on Integrated Disease Surveillance and Response was provided for district health management team members. In addition, an integrated maternal morbidity reduction and child survival tool was developed and introduced, capturing key indicators of all vertical programmes. Two main diseases of serious epidemic potential have occurred in Sierra Leone in the past 5 years: Lassa fever and yellow fever.

Neglected tropical diseases

Neglected tropical diseases remain a major concern in Sierra Leone. The rapidity with which they can cause deaths and the possibility of them becoming more widespread over the years make them diseases of major concern. However, because of their neglect, reliable data on the incidence and mortality from these diseases are scarce. Soil-transmitted helminths, onchocerciasis, lymphatic filariasis and yaws are the most important neglected tropical diseases in Sierra Leone.[16]

Yaws has recently re-emerged as a significant disease in some districts of the Northern Region, requiring public health intervention. There has been no survey done on yaws and so no data are available at present, but the Ministry of Health and Sanitation, in collaboration with WHO, is planning to conduct a survey in the known epidemic district of Bombali.

Non-communicable diseases and conditions

Noncommunicable diseases (NCDs) and conditions represent a significant burden in Sierra Leone. However, there is a dearth of up-to-date information on the prevalence of NCDs such as hypertension and other cardiovascular diseases, diabetes mellitus and sickle-cell disease.

Shifting the conventional mode of addressing NCDs from the tertiary care level to primary care and focusing on risk reduction is a necessary but difficult approach for their prevention and control. Mental health and substance abuse, disability, injuries, malnutrition and micronutrient deficiency represent a significant burden to the health and people of the country.[16]

Key Determinants
Risk factors for health

Risk factors for health are well known and have been partly addressed in this profile. With respect to drug use, a huge substance abuse problem has been reported in Sierra Leone. About 90% of admissions to the only psychiatric hospital in Sierra Leone are due to drug-related illnesses. Substances that are not under international control, such as alcohol, tobacco and sedatives, are also widely used.[16]

Although Sierra Leone set up a multidisciplinary task force in 2007 to advocate for the country’s accession to the WHO Framework Convention on Tobacco Control, the country is yet to ratify this convention and enact polices regulating smoking in public places.[17]

The physical environment

The most deadly vector-borne disease, malaria, kills over 1.2 million people annually, mostly African children under the age of 5 years.

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In Sierra Leone, the Ministry of Health and Sanitation’s National Environmental Health Policy stipulates that the vector control subdivision of the Ministry should be made functional and effective in order to support special disease control programmes, including malaria control, in the country. It also states that the vector control subdivision should create effective functional vector control units in all district and chiefdom headquarter towns. This is to ensure proper countrywide control of all vectors of public health importance.[18]

Sierra Leone’s urban centres (mainly in Freetown) are developing at an unprecedented rate, with increasing levels of urban dwellings, small-scale businesses and resulting pollution from sewage. As a result, improving sanitation is faced with the challenge of rapid urbanization coupled with inadequate infrastructure and services for solid waste disposal.

Food safety and nutrition

There is a draft National Food and Nutrition Policy, which is largely multisectoral, with a draft National Food and Nutrition Implementation Plan for 2012–2017.[19] Furthermore, the Smallholder Commercialization Programme Investment Plan of the Ministry of Agriculture, Forestry and Food Security is now nutrition sensitive, with nutrition indicators and inclusion of nutrition into its situation analysis process.

The Ministry of Health and Sanitation, through its Nutrition Unit and in collaboration with partners, is promoting mother and child nutrition through diverse interventions, including:[20]

Social determinants

Population movement across Sierra Leone´s borders is high. The vegetation ranges from mangrove along the coast to forest-covered hills and savannah further inland, which can harbour vectors of diseases.

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About two thirds of the population live in rural areas while a third live in urban areas, mainly in the capital city of Freetown.

The population of Sierra Leone, estimated at 5.5 million in 2008, has a natural increase rate of 2.3% per annum, with children 0–14 years representing about 45% of the population. The crude birth and death rates are 45 and 22 per 1000 population, respectively. The total fertility rate is among the highest in the world.



References
  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 Sierra Leone health and demographic survey, 2008: key findings. Calverton, Maryland, Statistics Sierra Leone and ICF Macro, 2009
  2. 2.0 2.1 2.2 2.3 2.4 National Health Sector Strategic Plan 2010–2015 (pdf 1.09Mb). Freetown, Government of Sierra Leone, Ministry of Health and Sanitation, 2009
  3. 3.0 3.1 3.2 3.3 3.4 Performance report. Freetown, Government of Sierra Leone, Ministry of Health and Sanitation, 2010
  4. National Health Policy final 2002 (revised 2009). Government of Sierra Leone, Ministry of Health and Sanitation
  5. National Health Sector Strategic Plan 2010–2015 Joint Programme of Work and Funding (JPWF) 2012–2014 (pdf 2.79Mb). Government of Sierra Leone, Ministry of Health and Sanitation, 2012
  6. 6.0 6.1 Health Compact (pdf 510.02kb). Government of Sierra Leone, 2011
  7. Gibril A et al. Sierra Leone health sector review 2004. Freetown, British Council, 2004
  8. Civil society report, 2011. Verbal communication
  9. Leigh B. Child survival and development mid-term review report for the programme 2008–2010. Sierra Leone, United Nations Children’s Fund, 2009
  10. African Health Workforce Observatory HRH fact sheet Sierra Leone (pdf 28.72kb). Brazzaville, WHO Regional Office for Africa, 2006
  11. Sierra Leone service assessment and readiness assessment (pdf 4.9Mb). Government of Sierra Leone, Ministry of Health and Sanitation, 2011
  12. 12.0 12.1 Sierra Leone HIV modes of transmission study. Know your epidemic, know your response (pdf 2.90Mb). Freetown, Sierra Leone, National AIDS Secretariat, 2010
  13. 13.0 13.1 National Leprosy and Tuberculosis Control Programme, annual report. Government of Sierra Leone, Ministry of Health and Sanitation, 2010
  14. 14.0 14.1 Sierra Leone service availability and readiness assessment (pdf 4.9Mb). Government of Sierra Leone, Ministry of Health and Sanitation, 2011>
  15. National Policy on Immunization. Government of Sierra Leone, Ministry of Health and Sanitation, Maternal and Child Health Division, 2002
  16. 16.0 16.1 16.2 16.3 WHO Country Cooperation Strategy 2008–2013 Sierra Leone (pdf 943.71kb). Brazzaville, WHO Regional Office for Africa, 2009
  17. Kennedy N. The Sierra Leone global youth tobacco survey report (draft copy). Government of Sierra Leone, Ministry of Health and Sanitation, 2008
  18. National Environmental Health Policy 2000, revised 2007. Government of Sierra Leone, Ministry of Health and Sanitation, 2007
  19. Sierra Leone National Food and Nutrition Policy (Word 156kb). Government of Sierra Leone, Ministry of Health and Sanitation 2009
  20. Nutrition Unit report. Government of Sierra Leone, Ministry of Health and Sanitation, 2010