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Field article
Through twice yearly mass
campaigns, Sierra Leone has achieved
high coverage of under-five Vitamin A
supplementation and de-worming at
91% and 85% respectively (SMART,
2010 3 ). Anaemia is still highly prevalent
at 76% and 46% in children under
five years and women of child bearing
age, respectively (DHS 2008). This
could be due to the high rates of
malaria and other parasitic infections,
poor dietary intake of iron-rich foods,
or a combination of reasons.
According to the Sierra Leone
District Health services baseline
survey (2009), 66% of pregnant women
had four or more antenatal care visits
as recommended, which is encouraging.
The same study indicates that 40%
subsequently delivered in a health facility.
Currently, insufficient numbers of health facilities
are equipped and staffed to acceptable
standards to provide emergency obstetric care.
The referral system in many districts is not
functional, often leading to dangerous delays in
the provision of comprehensive emergency
obstetric care.
Political will and policy environment
The government recognises that issues of
maternal and childhood health are key for a
healthy society and is committed to reducing
the high rates of maternal and child morbidity
and mortality. The government has taken steps
through the ‘President’s Agenda for Change’
and has developed a Basic Package of Essential
Health Services. An important initiative has
been the introduction of the Free Health Care
Initiative (FHCI) in April 2010 for all pregnant
women, lactating mothers and children of less
than five years. This initiative has considerably
improved access to care as follows:
• Increased consultations of children under 5
years from 933,349 to 2,926,431 after the
first 12 months of the FHCI (2009-2010) 4
• A 45% increase in institutional delivery
(87,302 pre FHCI to 126,477 one year after) 4
Sierra Leone is fortunate that the First Lady is a
champion of children and women’s affairs. She
has presided over a number of nutrition and
health advocacy events in the country. In a
recent National Nutrition and Food Security
Forum, the President (in a speech read on his
behalf by the Minister of Information)
expressed his concern at the current high
numbers of children affected by malnutrition
and he affirmed his government’s commitment
to firmly address the problem, by putting in
place dedicated policies and strategies to
reduce child hunger and undernutrition. There
is therefore a high level of political will at present,
ready to tackle the long standing problems
of malnutrition in-country.
The Ministry of Health and Sanitation
(MOHS) systems and structures are outlined in
Box 1. The MOHS has several policies in place,
including the National Health Policy, the
Reproductive Child Health Policy, the Food and
Nutrition Policy, which provide clear directions
for the entire health sector. The country is,
however, facing challenges in the effective operationalisation
of the policies. Most health
facilities are inadequately staffed, making it
difficult to implement outreach visits. There is
also a low staff/population ratio in Sierra
Leone. In 2010 there was a total of 2,787
AS Koroma/MOHS, Sierra Leone
Measuring length
Community Health Volunteers (CHVs), 906
Maternal and Child Health aides, 523 enrolled
nurses, 244 registered nurses/midwives, 154
Community Health Officers, 56 Medical
Officers, 21 Medical Superintendents and 72
District Health Management Team technical
members.
Rollout of CMAM
The Community based Management of Acute
Malnutrition (CMAM) programme started as a
pilot project in 2007 in Sierra Leone. It was triggered
by continuing high rates of malnutrition
in the post war years. The main aim of the
programme was to maximise coverage and
increase access to services by the highest possible
proportion of the malnourished population
across the country. It was also expected to create
a platform for comprehensive community
mobilisation over the long term.
Initially, the programme was piloted in four
districts – Bombali, Tonkolili, Kenema and
Western area. In each of the four districts, five
Outpatient Therapeutic Programme (OTP) sites
were established close to major towns for ease
of monitoring (as the programme was new,
monitoring was particularly important). Since
2007, the programme has been gradually
scaled-up, with the establishment of more OTPs
and Stabilisation Centres (SC) for the treatment
of complicated severe acute malnutrition
(SAM) cases. Additionally, Supplementary
Feeding Programmes (SFPs) were set-up at
centres to treat those presenting with moderate
acute malnutrition (MAM) and provide the
continuum of care for SAM children.
The initial targets for scale-up were:
• To achieve at least one OTP site per
chiefdom by 2010
• To achieve better coverage of remote areas
• To cater for the increased caseloads
expected following the adoption in 2010 of
the WHO growth standards
From the start, the CMAM programme has
been closely linked with other services
provided by the health system, such as antenatal
care, IYCF, immunisation and growth
monitoring interventions.
CMAM partners roles and
responsibilities
Ministry of Health and Sanitation (MOHS)
The MOHS is responsible for the overall leadership
of the programme, assuming multiple
responsibilities including policy formulation,
strategic planning, setting of standards and
regulations, ensuring collaboration between
national, district level and partners,
coalition building, resource mobilisation,
monitoring and oversight to
ensure effective implementation and
quality programming. The MOHS also
provides both the infrastructure and
the bulk of the health sector personnel
to implement CMAM.
Donors, UN agencies and NGOs
The main bilateral donors currently
funding the CMAM programme are
Irish Aid and the UK Department for
International Development (DFID).
Their combined investment in CMAM
in 2010 was almost $3 million. Donors
also fund the UN agencies, which
have specialised roles in supporting
the implementation of CMAM
through government, international or local
NGOs. The roles of the different UN agencies
and NGOs are briefly described below:
UNICEF supports community mobilisation,
OTP and SC components of CMAM. The
agency procures and provides supplies
(Plumpy’Nut, F75, F100, routine medication),
logistics, technical support and support for
national surveys (DHS, SMART, coverage
survey, MICS). UNICEF has also engaged NGO
partners to undertake active screening of
under-fives and social mobilisation for CMAM
and IYCF at community level in each district.
WFP supports the SFP component of CMAM
and SCs through provision of food to moderately
malnourished children and mothers
/caregivers of admitted SAM children. The
agency provides supplies, logistics, procurement
(dry rations – Corn Soya Blend, oil and
sugar). WFP NGO partners conduct the distribution
and monitoring of the food commodities
2
2010. The Nutrition Situation in Sierra Leone. Nutrition
Survey using SMART Methods, Final Report
3
See footnote 2.
4
Government of Sierra Leone. Health Information Bulletin.
Vol 2 No 3. Scaling up Maternal and Child Health through
Free Health Care, One year on.
Box 1: MOHS systems and structure
A Minister and two Deputy Ministers, all appointed
by the President, head the MOHS. The Ministry is
composed of an administrative and a technical wing
headed by the Permanent Secretary and the Chief
Medical Officer, respectively.
The Ministry has eleven directorates, with the Food
and Nutrition Programme located under the
Reproductive and Child Health Programme
Directorate. Other programmes in this directorate
include the School and Adolescent Health,
Reproductive Health and Child Health/ Expanded
Programme of Immunisation.
Sierra Leone’s health service delivery system is
pluralistic, whereby the government, religious
missions, local and international non-governmental
organisations (NGOs) and the private sector are all
involved in the provision of services.
Public health is delivered from three levels of health
facilities (from the lowest level to highest):
Peripheral Health Units (PHUs) – composed of 1200
Maternal and Child Health Posts, Community Health
Posts and Community Health Centres for frontline
primary health care.
Secondary Health Units – composed of 47 hospitals
in the districts, of which 18 are government owned,
19 faith-based, 8 private, located in districts and 2
non-governmental (NGOs).
Tertiary Health Care – composed of eight government
tertiary hospitals, of which three are regional
hospitals and five located in the Western area.
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