Republic
of Sierra Leone
Ministry of Health and Sanitation
National Health Policy
October 2002
This document sets
out the policy of the Government of Sierra Leone motivating and guiding the
health sector. The previous health policy was written in 1993, nearly 10 years
ago. Since then there have been a number of changes in the context facing the
health sector that lead to the need for an updating of that policy. Most
obviously, the civil war that the country has suffered has caused major
disruption to the health system in terms of damage to physical infrastructure,
loss of skilled professionals and, through the wider economic effects,
reduction in the real resources available to the health sector. It has also
resulted in changes in population patterns, and specific health problems
ranging from mental trauma through to physical disability. In addition to
these war-related effects, there are wider changes that many countries in
sub-Saharan Africa are facing which have implications for the health policy.
These include changing patterns of disease and demography such as the growing
problem of HIV/AIDS, the escalating problems of TB and malaria and the more
general epidemiological and demographic transition. They also include general
recognition of the need to re-examine the way in which the health care sector
is structured in particular with greater effective decentralisation,
partnership between public and private sectors, and greater transparency of decision-making
including the involvement of communities and other key stakeholders in
decision-making and accountability processes.
This policy is set
against this changing background and has been developed to provide a clear
direction for the health sector for the medium term. It includes policies
related to both the reconstruction of the health sector and the reform and
development of the sector. It also fully recognises the existence of specific
policies in defined technical areas. A number of general preliminary points
need to be stressed.
Firstly, it builds
on the previous policy initiatives. Much of the 1993 National Health Policy
and the subsequent National Health Action Plan (Core Programme) remains
relevant today and are reinforced in this policy. This new policy also fully
recognises the existence of specific technical policies in defined areas and
provides an overarching framework for these.
Secondly, in some
areas we have seen the need for the development of specific policies but, given
the numerous competing demands on the policy-makers’ attention, together with
the need for due consultation, have not yet finalised the details of these
policies. In such areas, this document points out the need for the development
of such policies without giving a particular policy stance at this point.
Thirdly, the policy
relates to the whole health sector and not simply the public services. There
are significant services provided by private providers of health care, and in
particular NGOs, and the contributions of these groups need to be considered
alongside that of the public sector within a holistic policy framework.
Fourthly, though
the focus of this document is on the provision of health care services, the
policy also recognises the effects, both positive and negative, of other
sectors on health and as such is deliberately a health rather than
simply a health care policy.
Lastly, this is a
policy document rather than a plan of action. It sets out the broad direction
that the health sector intends to pursue rather than the detailed activities to
achieve this. These latter will be provided by the planning process which will
be guided by this policy. As such, no specific time date has been set on the
policy though we anticipate that it will need to be revisited in the next five
years. We expect however that the broad principles laid down here will remain
valid for the foreseeable future.
The Ministry of
Health and Sanitation has developed the policy on the basis of broad
consultation. The process for the development of the policy involved meetings
with key stakeholders, the development of a consultative paper and culminated
in a two-day workshop in July 2002 attended by over 150 key stakeholders. As
such it is expected that the policy will be widely accepted by the key partners
in the health sector and used as a joint platform to improve the health of the
citizens of Sierra Leone.
Table
of Contents
Foreword by Hon Minister of Health and Sanitation
1 Introduction
2 Goals, objectives and national health
priorities
3 Governance of the health sector
4 Planning and policy processes
5 Health care delivery
6 Health education, health promotion and
intersectoral activities
7 Role of different agencies in the
health system
8 Decentralisation
9 Human resources for the health sector
10 Finance for the health sector
11 Health Sector infrastructure
12 Drug supplies
13 Health Management Information System
1.1
The policy is structured as follows. It
firstly deals with goals and priorities of the health sector. It then sets out
sets out the policy on governance of the health sector and the processes for
implementing the policy and subsequent plans. This is followed by broad
policies on health care delivery, health education, health promotion and
intersectoral activities. It then turns to the role of different agencies in
the health system. Finally It sets out policies on specific resources for the
health sector – human resources, finance, infrastructure and drugs, and the
Health Management Information system.
2.1
The overall goal of the health sector is to
maintain and improve the health of all Sierra Leoneans resident within the
country.
2.2
The Government of Sierra Leone is committed to
pursuing such a goal in an equitable manner. It will work towards ensuring
that all citizens have access to basic good quality health care. It has special
responsibility to ensure the health of those citizens who are particularly
vulnerable as a result of poverty, the results of conflict, gender or specific
health problems.
2.3
The Government of Sierra Leone also has
responsibility for ensuring the provision of adequate public health services
(including sanitation), for food safety and for effective action against
specific communicable diseases.
2.4
The health of a country is not the result of
health services alone, but can be affected both positively and negatively by
the activities of a number of other sectors. The Ministry of Health and
Sanitation has a responsibility to provide leadership and health-related
advocacy to such sectors to ensure their activities are health promoting.
2.5
Sierra Leone faces a
number of major health problems. However, the resource constraints (and in
particular those related to availability of finance and health care
professionals) mean that priorities have to be set as to the key health
problems that the health sector will focus on. This does not imply that other
health problems will be ignored; but rather that they will not receive targeted
national investment. It is also recognised that there are differences in the
prevalence and incidence of specific health problems (such as lassa fever)
between districts. As such there will also be opportunities, within the
planning processes, for the local setting of priorities within the national
framework.
2.6
On the basis of set criteria, the current national priority
health problems are:
· Malaria
· Sexually Transmitted Infections including HIV/AIDS
· TB
· Unsatisfactory reproductive health including maternal and neo-natal
mortality
· Acute Respiratory Infections
· Childhood immunisable diseases
· Nutrition-related disease
· Water, food and sanitation-borne diseases
· Disability
· Mental illness
2.7
Technical policies exist for a number of these
health priorities, which set specific objectives, targets, strategies and where
appropriate treatment protocols. Further technical policies will be developed
in each of the remaining priority areas and the existing ones updated as
necessary.
3.1
The Government of Sierra Leone is committed, as
part of its post-war reconstruction, to the development of a transparent and
accountable public sector. The Ministry of Health and Sanitation will ensure
that its management structures respond to this requirement. Key elements of
this are as follows.
3.2
The Ministry will ensure that it has a clear
communications strategy for relaying information to the general public and key
stakeholders.
3.3
At all levels of the service there will be
opportunities for input by key stakeholders and communities in decision
making. At the national level this will occur through both the parliamentary
processes and the national Council for Health, Nutrition and Sanitation (see
Section 6.2). At the levels of District, Hospital and below, this will be
ensured through the inclusion in the decentralisation arrangements to be
developed, of community and professional participation in the decision making
processes with particular attention to ensuring adequate representation of the
voiceless.
3.4
Consultation processes for key decisions in the
health sector will be developed. This will ensure that professional bodies
including medical, nursing and paramedics, together with key stakeholders such
as NGOs, the private health providers and international partners will be
consulted on key decisions.
3.5
The Ministry of Health and Sanitation will
produce, as part of its planning processes, an annual report on the Health of
the Nation.
4.1
The war period was inevitably characterised by
short-term planning processes. In order to implement the broad policies laid
out in this document the Ministry of Health and Sanitation will develop and
strengthen the planning and policy-making system.
4.2
It will develop and/or revise a number of
specific technical policies, including those referred to in Section 2.7. Each
of these will include clear time-bound objectives for the technical area.
4.3
It will revive and strengthen the previous
three-year rolling plan system with emphasis, through the emerging
decentralised structures, on bottom-up planning.
4.4
A national plan will be developed to provide
strategies for implementation of this policy and to provide a framework for
district and hospital plans. This will include time-bound indicators for
monitoring the success of the plan and will be reviewed as part of the annual partners’
meeting and annual review.
5.1
There is a strong history of Primary Health Care
within the health sector of Sierra Leone. The Government remains committed to
this approach with an emphasis on primary care services and prevention as
cost-effective strategies. As such the delivery of health care will be based
on the following principles:
· The development of an integrated health system which has clear and
inter-linked roles for the primary, secondary and tertiary levels of care.
· The strengthening of the referral system between the levels of care
to ensure the efficient use of different levels of specialism, and appropriate
feedback between health care professionals
· The importance of ensuring involvement of communities, and the
voiceless within these communities, in decisions about health
· An emphasis where appropriate on preventive strategies
· Collaboration between sectors
5.2
In order to achieve the above principles, the
Government will ensure that there are clear guidelines as to the services to be
provided at each of the primary, secondary and tertiary levels. In particular
the current PHC operational handbook will be updated to specify the inputs and
the resultant services to be provided at the primary level. Services will
include basic curative services, family planning and STI services, ante-natal
care and routine deliveries, childhood immunisation and health education. A
new operational handbook for secondary level services will also be developed
specifying the services to be provided at the district hospital level.
Strategies to discourage the use of the secondary care level for primary
services will be developed on the grounds of cost-effectiveness. Referral
mechanisms between different levels of the public system and between public and
private providers will also be strengthened.
5.3
Emphasis will be placed on ensuring that all
citizens of Sierra Leone have access to basic health care provided at the
primary level, and with appropriate mechanisms for referral to the secondary
level. In order to achieve this, and in recognition of the damage to
infrastructure and population displacement caused by the war, an assessment
will be carried out in each district to determine the appropriate location of
primary facilities.
5.4
The Ministry of Health and Sanitation is
responsible for ensuring adequate public health programmes for priority
diseases. As part of the decentralisation process to which the government is
committed (and which is further elaborated on in Section 8), current vertical
programmes will be integrated, as far as is technically possible, within the
district services.
5.5
All health care providers, both public and
private, will be expected to conform to the specific technical policies and
treatment protocols referred to in Section 2.7.
5.6
The focus of the health care delivery system
will be at primary and secondary level and within this on primary care. This
will be reflected in the allocations of recurrent budgets to reflect these
priorities. However the current tertiary facilities are in poor physical
condition and these will be renovated. Bed numbers at tertiary level will not,
however, in the short-term, be expanded. However there are specialist services
such as specialist laboratories which need to be provided at a national level particularly
in relation to priority health problem. These will be developed.
6.1
As part of the primary care philosophy to which
the Government is committed, emphasis will be placed on appropriate health
education and health promotion activities. This will occur at all levels of
the health system. This will include activities aimed at changing positively
the life style of individuals and communities. It will also include advocacy
activities aimed at promoting policies in other sectors of the economy, which
are positive to health and discouraging or legislating against activities that
lead to a reduction in health.
6.2
A national Council for Health, Nutrition and
Sanitation chaired by the Hon Minster for Health and Sanitation will be set up
to co-ordinate health-related activities across different sectors.
6.3
The Ministry of Health and Sanitation will also
continue to play a technical leadership role in the HIV/AIDS intersectoral
strategy through the National AIDS Council.
7.1
Within the health system there is a variety of
different providers of health care. These include the public sector, NGOs and
church-related agencies, private-for-profit clinics, commercial companies and
traditional practitioners. The Government of Sierra Leone recognises the
important services provided by many of these agencies and will work towards
ensuring complementary and positive relations between the different agencies.
7.2
Within government, the Ministry of Health and
Sanitation is responsible for setting policy for the health sector and ensuring
that services provided by the different agencies work towards this policy and
meet acceptable minimum standards.
7.3
The role of the Ministry of Health and
Sanitation Headquarters is primarily to provide policy and planning leadership
(both strategic and technical) for the whole sector, to ensure an equitable
financing and resource allocation system for the health sector, to provide
national leadership on health promotion and intersectoral collaboration
including any appropriate legislation, and to regulate all health care
providers to ensure quality standards are set and maintained.
7.4
This role requires a shift by the Ministry of
Health and Sanitation Headquarters away from current involvement in direct
management of health services. It also requires a change in management roles
and responsibilities for districts and hospitals. Systems consistent with
these new roles and training of staff to perform them will be developed and
carried out.
7.5
There are currently a number of vertical
programmes which are managed from the national level. It is intended to
integrate the management of these as far as possible, into the general district
health services, as long as their technical effectiveness is not compromised.
A national role of technical leadership and monitoring will be maintained and
strengthened. This policy of integration will be linked to the development of
decentralisation.
7.6
It is important, given the shortage of
resources, that there is minimal duplication of services. Where it is
considered that an institution in the NGO or private sector is already
providing, or is capable of providing, a service on behalf of government, at an
appropriate level of quality and cost, arrangements will be explored for
contracts and subventions for such services. Such services could include
clinical, laboratory ancillary, civil works and maintenance.
7.7
NGOs, including the Church-related organisations
have in the past made a significant contribution to the provision of services
and training in the health sector and the Government of Sierra Leone continues
to welcome the contribution of such organisations. During the war period the
well-established NGOs were joined by international NGOs with a special focus in
such situations. During this period, some registration requirements were
relaxed in the interest of speedy response. As Sierra Leone enters the
reconstruction and rehabilitation phase, it will be important to revive and
strengthen registration procedures as one means of ensuring appropriate
complementarity with public sector services and other NGOs. As such NGOs will
continue to be required to register with Government and their staff with the
relevant Professional Councils. Clear guidelines on the approval mechanisms,
including those related to the areas of operation, at both national and
district levels will be developed in conjunction with the NGO Unit of the
Ministry of Development and Planning and made operational. Only those
organisations which have complied with such procedures will be eligible for
access to government supplied drugs and vaccines and government training
schemes, and relief of import duties. In some cases, NGOs will be contracted
by the Ministry of Health and Sanitation to provide services on its behalf. In
the spirit of transparency and accountability, all NGOs operating in the health
field will be required to provide annual reports to government on their
activities and financial arrangements. Mechanisms to ensure collaboration
between the NGO and public sectors at both the national and district levels
will be strengthened.
7.8
Private for profit providers will also be
required to register with the Professional Councils. As for-profit organisations
they will not be generally eligible for government support. However where they
are seen to be providing a service on behalf of government (for example, in the
field of childhood immunisation) they will be eligible for support in terms of
vaccines and training. They may also (as stated in Section 7.6) be contracted
for the provision of services on behalf of government.
7.9
Some private health care provision is of low
quality, inappropriate and, in some cases, illegal. Standards will be
maintained through the regulatory agencies including the Professional Councils
and Boards and the public sector managers such as at the District Health
Management level.
7.10
Traditional practitioners including Traditional
Birth Attendants have a long history in Sierra Leone. The Government of Sierra
Leone recognises the important services provided by some of these, but is also
concerned that others may unknowingly not be providing services in the best
interests of their patients. A code of practice will be drawn up which will,
inter alia, specify the relationship (including supervision arrangements)
between such practitioners and the District Health team, and where necessary,
appropriate training will be developed to impact positively on the standard of
their se4vice delivery..
7.11
Given the economic situation of Sierra Leone for
the foreseeable future, the Government will seek an increase in the level of
support from international partners in the provision of finance and technical
advice both for development activities and to support the operating costs of
the health sector. Co-ordination mechanisms will be strengthened to ensure the
avoidance of duplication and the appropriate use of external support.
8.1
The Government of Sierra Leone is committed to
decentralisation of public services, with a view to providing greater local
determination of priorities and management autonomy to deal with these. Various
statutory instruments to allow this, including the Hospital Boards Act, exist
already, and as part of a forthcoming project on health systems, these will be
reviewed by a Task Force set up by the Ministry of Health and Sanitation which
will include key stakeholders. This will develop a detailed policy for the
decentralised structures which will respond to the needs of the health sector,
whilst taking account of the wider requirements of the government system. It
will also review the potential role of Provinces which have been sidelined due
to a lack of logistics and other support.
8.2
The final model for decentralisation will be
influenced by a number of considerations including central government plans for
the decentralisation of other sectors, the requirements of the Ministry of
Finance and the advice of the Anti-Corruption Commission. However it is likely
that the form decentralisation will take is that of deconcentration.
8.3
In order to achieve appropriate and effective
decentralisation, a programme of capacity-building will be required. Following
agreement on the overall decentralisation model, specific activities will be
undertaken to develop appropriate management systems, and develop training for
the new roles.
9.1
There is a critical shortage of staff from a
range of health professions currently working in the health sector and particularly
in the remote districts. This shortage stems from a number of causes. This
includes losses resulting from the war due to both mortality and emigration.
It also is affected by the inadequate levels of pay and related conditions of
service.
9.2
A human resource plan will be drawn up. This
will map the current situation across the whole health sector and, using trend
analysis, will identify the likely situation over the next 10 years. It will
also review the current set of staff cadres in order to identify areas where
greater efficiency can be found.
9.3
There are currently, significant imbalances in
the distribution of health professionals across the districts of Sierra Leone. The human resource plan will investigate this and develop strategies to
redress the imbalances in the pursuit of equity. This could for example,
include the use of enhanced incentive payments for hardship areas.
9.4
Whilst the Government is clearly constrained by
the current economic situation in Sierra Leone, it is also aware of the
importance of providing appropriate terms and conditions for public sector
staff and will seek means to improve these. This includes ensuring that
promotion occurs on the basis of competence and that appropriate staff
development processes, including appraisal, exist. With the development of
decentralisation, the possibility exists of changing the formal employment
arrangements including giving greater powers to district and hospital levels.
This possibility will be explored.
9.5
The current situation concerning the rights of
public sector medical staff in private practice is both unclear and varied
between institutions in the country. As part of the review of terms and
conditions, this will be revisited and a standard policy set.
9.6
NGOs operating in Sierra Leone have developed
individual terms and conditions of service for their staff. In addition in a
number of cases, they have developed incentive schemes for government employees
working alongside their own project staff. Whilst this was understandable
during the period of emergency, this situation is now leading to inefficiencies
and tensions. The Government will work with NGOs to develop a common code of
practice for the employment of both NGO staff and government staff receiving
incentive payments from NGOs.
9.7
The Government will also take steps to encourage
the return of Sierra Leonean health professionals currently working outside of
the health sector or outside of the country.
9.8
Whilst the Government will work towards ensuring
that the majority of health positions are held by Sierra Leoneans, in the
medium term a number of expatriate professionals will be required to fill
vacancies. Whilst such professionals will be welcomed into the health sector,
they will be required to meet the standards of the relevant professional
councils and boards.
9.9
These Councils will be strengthened to ensure
they have the capacity to carry out these regulatory roles. This includes
regulation of street pharmacists and other unqualified health providers. They
will also be tasked to ensure that professionals operate under the ethical
standards set.
9.10
The human resource plan will identify the
training needs of the health sector, where these can most appropriately be met
and any related resource and institutional implications. Wherever possible,
training will be conducted within Sierra Leone, though for some specialised
training, out-of country courses will be needed. In the short-term two areas
of training will be emphasised. Firstly, given the priority placed on primary
care, training needs related to this will be targeted. Secondly, given the
development of a decentralised system, management training related to this (and
including financial and personnel management) will be prioritised.
9.11
Given the critical importance of in-country
training at this time of reconstruction and development, the in-country
training institutions will be given high priority in the plans of the health
sector.
9.12
The Ministry of Health and Sanitation together
with the University training institutions for health care delivery will keep
the provision of training vis a vis the personnel needs of the health sector
under constant review.
10.1
The current levels of finance to the health
sector are widely regarded as being inadequate for even the provision of basic
services. The Government of Sierra Leone will work, within the constraints of
the economy and other competing priorities, to increase the finance available
to the health sector to a level commensurate with other countries in a similar
economic condition. The HIPC initiative provides an important mechanism
whereby government commitments to the health sector can be increased. The
Ministry of Health and Sanitation will also continue to take responsibility for
the co-ordination of external financing to the health sector as stated in
Section 7.11.
10.2
There are currently a number of schemes
operating at different institutions to charge fees to patients and users of
services. These have arisen as a result of the Bamako Initiative and various
complementary cost recovery schemes. The Ministry of Health and Sanitation
will review such schemes and develop a unified charging system consistent with
its principle of equity. This will include mechanisms for exemptions for
vulnerable groups and for those conditions which, on public health grounds,
warrant exemptions. GOSL policies, in pursuance of Poverty Alleviation, to
exempt school-going children, under fives, pregnant women, lactating mothers up
to 12 months duration and citizens over 65 years in age will be taken account
of in the development of the unified charging scheme. The charging policy will
also take account of the services provided by NGOs and the church-related
sector.
10.3
The Ministry of Health and Sanitation will also
review the resource allocation system to ensure that allocations of central
funding to individual districts and hospitals are consistent with equity and
allocative efficiency and take account of differential unit costs between
districts. It will also, with the Ministry of Finance, work towards improving
the speed of disbursement of approved budget funds to such institutions.
10.4
The Ministry of Health and Sanitation will, in
the medium-term, investigate the possibility of a national health insurance
scheme.
11.1
The Government is committed to ensuring that an
appropriate infrastructure is available to support the provision of priority
services. In line with its priority on primary and secondary care provision it
will, in the short to medium term, focus on ensuring that there is an
appropriate network of facilities throughout Sierra Leone allowing access by
all citizens to primary and secondary care. Given the change in population
distribution that has occurred as a result of the war, each district will
develop a plan for the location of such facilities for approval by the Ministry
of Health and Sanitation.
11.2
The Ministry of Health and Sanitation will work
to ensure that there is adequate communication between facilities and different
levels of care to enable referral, and to provide supportive supervision. Such
communication includes both transport and radio/telephones.
11.3
The Ministry of Health and Sanitation will work
towards rehabilitating the tertiary level facilities though, as stated in
Section 5.6, will not expand the level of services currently provided.
12.1
The provision of good quality care is dependant
on the availability of safe and affordable medical supplies. Such supplies
should be in accordance with the Essential Drug list. The Ministry of Health
and Sanitation will ensure that there are appropriate levels of resources to
operationalise the Pharmacy and Drug Act (2000) and, where appropriate, update
the 1993 Drug Policy to cover the areas of procurement, stock management, distribution
and quality control.
12.2
As part of this process, the Ministry of Health
and Sanitation will, in particular, take steps through the Pharmacy Board to
reduce the number of unlicensed street pharmacists whose activities endanger
the health of their customers and the general public.
13.1
The monitoring of progress of policies and plans
is dependant on the availability of reliable and standardised information.
The Ministry of Health and Sanitation will develop, in conjunction with key
partners, a unified Health Management Information System to meet these needs.
A technical policy on Health Management Information will be developed which
will specify reporting requirements from all providers to the Ministry of
Health and Sanitation and appropriate feedback processes.
13.2
The community has a right to timely and accurate
information especially regarding security, health and general welfare. The
Ministry of Health and Sanitation is the official source of information
regarding health and epidemics and is committed to meeting the needs of
communities for information.
14 As one of the sources of health information, and to encourage
evidence-based policy and practice, the Ministry of Health and Sanitation will
encourage the conduct of research into health and health services. It will set
up a Research Board to approve such research on grounds of appropriateness and
ethics.