1.1 Country Profile - MOHS SIERRA LEONE | …
-914400-914400MINISTRY OF HEALTH AND SANITATION00MINISTRY OF HEALTH AND SANITATION-98996536203??0??-914400201579HEALTH SECTOR RECOVERY PLAN (2015 – 2020)00HEALTH SECTOR RECOVERY PLAN (2015 – 2020)466725026797000-87345726808400-10585456350???? 1143000-4445“Government of Sierra Leone working together with partners to build a resilient health system”00“Government of Sierra Leone working together with partners to build a resilient health system”TABLE OF CONTENTS TOC \o "1-3" \h \z \u MINISTER’S FOREWORD PAGEREF _Toc419323311 \h 6REMARKS PAGEREF _Toc419323312 \h 7ACKNOWLEDGEMENTS PAGEREF _Toc419323313 \h 8ACRONYMS PAGEREF _Toc419323314 \h 9EXECUTIVE SUMMARY PAGEREF _Toc419323315 \h 111.BACKGROUND PAGEREF _Toc419323316 \h 141.1 Country Profile PAGEREF _Toc419323317 \h 141.2 Organization of the Sierra Leone’s health system PAGEREF _Toc419323318 \h 141.3 National Strategies informing the health sector recovery plan PAGEREF _Toc419323319 \h 161.3.1 Agenda for Prosperity (2013 – 2018) PAGEREF _Toc419323320 \h 161.3.2 The Basic Package of Essential Health Services (BPEHS, 2010) PAGEREF _Toc419323321 \h 161.3.3 National Health Sector Strategic Plan (NHSSP 2010-2015) PAGEREF _Toc419323322 \h 171.3.4 Free Health Care Initiative (FHCI, 2010) PAGEREF _Toc419323323 \h 171.3.5 Joint Program of Work and Funding (JPWF, 2012-2014) PAGEREF _Toc419323324 \h 181.3.6 National Health Compact (2011) PAGEREF _Toc419323325 \h 181.3.7 Results and Accountability Framework 2010-2015 (2011) PAGEREF _Toc419323326 \h 192.SITUATION ANALYSIS PAGEREF _Toc419323327 \h 202.1 Status of the health sector prior to EVD outbreak PAGEREF _Toc419323328 \h 202.2 Impact of Ebola on the health sector PAGEREF _Toc419323329 \h 223.FROM VISION TO RECOVERY PLANNING PAGEREF _Toc419323330 \h 254.THE HEALTH SECTOR RECOVERY FRAMEWORK PAGEREF _Toc419323331 \h 284.1 Key Priority Areas PAGEREF _Toc419323332 \h 284.2 Basic Package for Essential Health Services (2015) PAGEREF _Toc419323333 \h 284.3 Sequencing of Events PAGEREF _Toc419323334 \h 305.KEY PRIORITY ONE: PATIENT & HEALTH WORKER SAFETY PAGEREF _Toc419323335 \h 325.1 Getting to Zero and Transition Phase PAGEREF _Toc419323336 \h 325.1.1 Establish triage procedures for safe restoration of essential health services PAGEREF _Toc419323337 \h 335.1.2 Strengthening Infection Prevention and Control measures PAGEREF _Toc419323338 \h 335.2 Early Recovery Phase and beyond PAGEREF _Toc419323339 \h 346.KEY PRIORITY TWO: HEALTH WORKFORCE PAGEREF _Toc419323340 \h 356.1 Getting to Zero and Transition Phase PAGEREF _Toc419323341 \h 356.2 Early Recovery Phase PAGEREF _Toc419323342 \h 366.2.1 Increase district/facility skilled workforce, emphasizing underserved areas PAGEREF _Toc419323343 \h 366.2.2 Establish and deliver in-service health worker training on BPEHS PAGEREF _Toc419323344 \h 376.3 Recovery Phase PAGEREF _Toc419323345 \h 376.3.1 Update remuneration packages PAGEREF _Toc419323346 \h 376.3.2 Enhance training including at post-graduate levels PAGEREF _Toc419323347 \h 386.3.4 Strengthen regional referral hubs PAGEREF _Toc419323348 \h 386.3.5 Strengthening career pathways PAGEREF _Toc419323349 \h 396.3.6 Continuing professional development (CPD) PAGEREF _Toc419323350 \h 396.3.7 Establishing a local post-graduate medical training PAGEREF _Toc419323351 \h 397.KEY PRIORITY THREE: ESSENTIAL HEALTH SERVICES PAGEREF _Toc419323352 \h 407.1 Getting to Zero and Transition Phase PAGEREF _Toc419323353 \h 407.1.1 Restore the critical elements of the BPEHS PAGEREF _Toc419323354 \h 407.1.2 Strengthen communicable and non-communicable diseases control PAGEREF _Toc419323355 \h 427.1.3 Establish demand-driven essential medicines list supply system PAGEREF _Toc419323356 \h 427.2 Early Recovery Period PAGEREF _Toc419323357 \h 437.2.1 Environmental health PAGEREF _Toc419323358 \h 437.2.2 Ambulance and fleet management services PAGEREF _Toc419323359 \h 447.2.3 Expanding national 117 dial-in/alert center for broader health information PAGEREF _Toc419323360 \h 447.2.4 Rehabilitation and facility equipping PAGEREF _Toc419323361 \h 457.3 Recovery Phase PAGEREF _Toc419323362 \h 458.KEY PRIORITY FOUR: COMMUNITY OWNERSHIP PAGEREF _Toc419323363 \h 468.1 Getting to Zero and Transition Phase PAGEREF _Toc419323364 \h 478.1.1 Establish community groups of key stakeholders and networks PAGEREF _Toc419323365 \h 478.1.2 Engage community groups and networks in community surveillance PAGEREF _Toc419323366 \h 478.1.3 Develop key policies, strategies and guidelines on community engagement PAGEREF _Toc419323367 \h 488.2 Recovery Phase PAGEREF _Toc419323368 \h 488.2 1 Engage community groups of key stakeholders in BPEHS implementation PAGEREF _Toc419323369 \h 488.2.2 Ensure key community stakeholders are engaged in community-based surveillance PAGEREF _Toc419323370 \h 498.2.3 Develop key policies, strategies and guidelines on community engagement PAGEREF _Toc419323371 \h 499.KEY PRIORITY FIVE: INFORMATION & SURVEILLANCE PAGEREF _Toc419323372 \h 509.1 Getting to Zero and Transition Phase PAGEREF _Toc419323373 \h 519.1.1 Integrated Disease Surveillance and Response (IDSR) PAGEREF _Toc419323374 \h 519.1.2 International Health Regulations (IHR) PAGEREF _Toc419323375 \h 519.1.3 Establish surveillance related coordination and communication PAGEREF _Toc419323376 \h 519.2 Early Recovery Phase PAGEREF _Toc419323377 \h 529.2.1 Build surveillance capacity PAGEREF _Toc419323378 \h 529.2.2 Establish a functional national laboratory network PAGEREF _Toc419323379 \h 529.2.3 Strengthen Health management information systems (HMIS) PAGEREF _Toc419323380 \h 529.3 Recovery Phase PAGEREF _Toc419323381 \h 539.3.1 Further strengthening of IDSR PAGEREF _Toc419323382 \h 539.3.2 Increase capacity of quality assessment, information system, and supervision PAGEREF _Toc419323383 \h 539.3.3 Strengthen Health management information systems (HMIS) PAGEREF _Toc419323384 \h 5310.ENABLING ENVIRONMENT PAGEREF _Toc419323385 \h 5510.1 Continuous improvement to leadership and governance at all levels PAGEREF _Toc419323386 \h 5610.2 Strengthen capacity of districts to implement the recovery plan PAGEREF _Toc419323387 \h 5610.3 Improve accountability for health sector recovery implementation PAGEREF _Toc419323388 \h 5610.4 Efficient and sustainable financing mechanism PAGEREF _Toc419323389 \h 5710.5 Develop and implement cross-sectoral initiatives PAGEREF _Toc419323390 \h 5710.6 Improved policy and legal environment PAGEREF _Toc419323391 \h 5711.COSTING & FINANCING PAGEREF _Toc419323392 \h 5811.1 Costing PAGEREF _Toc419323393 \h 5811.1.1 Baseline Scenario PAGEREF _Toc419323394 \h 5811.1.2Moderate Scenario PAGEREF _Toc419323395 \h 5811.1.3 Aggressive Scenario PAGEREF _Toc419323396 \h 5811.2 Financing the health sector recovery plan PAGEREF _Toc419323397 \h 5812.IMPLEMENTATION ARRANGEMENTS PAGEREF _Toc419323398 \h 6312.1 Leadership and Governance structures PAGEREF _Toc419323399 \h 6312.2 Operational Structures PAGEREF _Toc419323400 \h 6312.2.1 MOHS’ Delivery Operational Team PAGEREF _Toc419323401 \h 6312.2.2 Directorate of Health Systems, Policy, Planning & Information PAGEREF _Toc419323402 \h 6312.2 3 Integrated Health Projects Administration Unit PAGEREF _Toc419323403 \h 6312.3.4 District Health Management Teams PAGEREF _Toc419323404 \h 6412.3.5 Regional Hubs PAGEREF _Toc419323405 \h 6412.4 Key State Institutions PAGEREF _Toc419323406 \h 6412.4.1 Health Services Commission (HSC) PAGEREF _Toc419323407 \h 6412.4.2 National Pharmaceutical Procurement Unit (NPPU) PAGEREF _Toc419323408 \h 6412.5 The role of partners PAGEREF _Toc419323409 \h 6512.5.1 Donor partners PAGEREF _Toc419323410 \h 6512.5.2 Technical Assistance partners PAGEREF _Toc419323411 \h 6512.5.3 Implementing partners PAGEREF _Toc419323412 \h 6513.RISK ANALYSIS AND MITIGATION PAGEREF _Toc419323413 \h 6614.MONITORING & EVALUATION PAGEREF _Toc419323414 \h 67MINISTER’S FOREWORD 0-317500Back in November 2014, a seed was planted when my Ministry developed a vision for the health sector. Working with Top and Senior Leadership Teams of the Ministry, we presented that vision to the development partners at a Health Sector Coordinating Committee meeting in early December 2014 – One of the most significant health sector meetings we have had since the outbreak of the Ebola Virus Disease epidemic. As the weeks passed, relentless effort from my team within the Ministry and the generous support of our partners, both financial and technical, helped to further refine that vision. Four months later, I am pleased to see the outcome of the effort. Collectively, we have proven that a lot can be done in a very short space of time when a few dedicated people come together with strong leadership and support from the Ministry’s leadership. We have turned what initially seemed very complex into a distilled multi-year and artfully sequenced health sector recovery investment plan for the period 2015 to 2018. All I had was a vision, which is for the country to have a strong and responsive health system that contributes to the country’s agenda for prosperity and socio-economic development for the Sierra Leonean population. This plan, in its entirety, defines step-by-step, how the Government of Sierra Leone, in particular the Ministry of Health and Sanitation and our partners will make that vision a reality. This is an ambitious yet feasible investment plan. I urge that all of us – Ministry of Health and Sanitation, Donors, technical and specialized agencies, local and international Non-Governmental Organizations in the health sector – to work together, complementing each other’s efforts in order for us to achieve the ideals of this plan. As we strengthen cross-sectoral and inter-Ministerial collaboration, our relationship with other Ministries will also be very instrumental. The response to the Ebola Virus Disease outbreak has taught us that we need those relationships to be much stronger than they were before the outbreak. Together, we can achieve more.It is reassuring that the health sector and the recovery investment plan have the support of our President - His Excellency, Dr Ernest Bai Koroma. I would also like to assure all Sierra Leoneans of my commitment to support the implementation of the strategies and interventions listed in this plan. I will be very keen to see continuous measurement of our collective efforts so we can go back to the drawing board whenever we see that our original strategies and interventions are achieving the intended results. It through constant reflection that we can resolve the bottlenecks we are bound to face during the six years of implementation. ____________________________Honourable Dr Abu Bakarr FofanahMinister of Health and SanitationFreetown30 June 2015REMARKS9017027686000In 2009, the Ministry of Health and Sanitation developed a Health Sector Strategic Plan for the period 2010 to 2015. The plan was developed around strengthening of the six key pillars of the health system. To support the national strategy, a basic package of essential health services was developed in 2010. The intention then was to improve infant and maternal health with the aim of progressively moving towards universal coverage. Although we were making progress towards achieving the targets of the Millennium Development Goals 4 and 5, the health system remained weak and less capable of handling major catastrophes as complex as the Ebola Virus Disease outbreak. We had fewer human resources for health to address the health needs of our population and the few we had were severely affected due to lack of infection prevention and control. Due to limited infrastructure in our health facilities, service delivery was also significantly affected. It is therefore befitting that the thinking around health sector recovery would be framed along the components of the health system that were severely affected during the Ebola Virus Disease outbreak. The health sector recovery plan is made up of five pillars: (i) Patient and Health Worker Safety, (ii) Human Resources for Health, (iii) Essential health services; (iv) Community Ownership; and (v) Information and Surveillance. Interventions across these five pillars are articulated across the transition period, early recovery as well as the recovery phase. The health sector will focus the initial 6-9 months on Getting to Zero and Transition from a full scale fight against EVD using the right-sizing approach. When right-sizing the EVD response, we will ensure that we maintain a core response team at a few Ebola holding and treatment centres to address sporadic cases of EVD, while we refocus interventions and majority of resources that came for toward the national rebuilding efforts. The Early Recovery phase will continue interventions implemented during the transition period through early 2016. During this phase, we will incrementally add new interventions that were not part of the transition phase as we prepare the health system for a full recovery. This phase will be followed by the Recovery phase. Interventions implemented during this period will return the health system to the same state as pre-Ebola. Additional interventions will be included to serve as a platform to build a resilient health system by 2020. The final and longer term phase will focus on implementing interventions that focus more specifically on enabling the health sector environment to deliver the Basic Package of Essential Health Services. This health sector recovery plan, the revised basic package for essential health services and associated operational, Monitoring and Evaluation Plans, provide a solid roadmap for delivering the Government of Sierra Leone’s promise to its people of a better health for all. I would like to acknowledge the leadership and commitment of the Director for Health Systems, Policy, Planning and Information and his team for leading the development of this post- Ebola recovery plan.____________________________Dr Brima KargboChief Medical OfficerMinistry of Health and SanitationACKNOWLEDGEMENTS021145500The process to develop a national plan is very intensive and usually lasts many months, sometimes over a year. The post-Ebola recovery planning process coincided with a time when our National Health Sector Strategic Plan 2011 – 2015 was nearing its expiration. The Ministry of Health and Sanitation made a conscious decision to develop a separate post-Ebola health sector recovery plan from the usual national health sector strategic plan to allow flexibility in approach, output and design. As a recovery plan, it is not as exhaustive as a national health sector strategic plan ought to be. A subsequent national health sector strategic plan for the period 2015 – 2020 will include this recovery plan and the longer term interventions that will ensure we achieve our mission – to build a resilient health system. The development of this health sector recovery plan was highly consultative and involved a series of consultative meetings that started on 02 December 2014 when the Minister of Health and Sanitation presented to senior Ministry officials his vision for rebuilding the health system. Since then, consultative meetings were held with development partners (04 December 2014), health sector steering groups (16 January 2015), Stakeholder consultation (22 – 23 January 2015), District planning (05 – 08 March 2015) and concluded with a stakeholder validation meeting (25 – 26 March 2015). These meetings were very significant as each subsequent one helped to further refine the plan to its current form. Many institutions, organizations and individuals have contributed to the plan. Indeed a plan of this magnitude in terms of scope and significance would not have been possible without the contribution of everyone that was involved. The dedication and commitment of my team is highly commendable. I would like to thank all Chairpersons and Secretaries of the reconstituted Health Sector Steering Group for their tireless effort during the planning process. The Ministry of Health and Sanitation is grateful to all partners and recognizes the strong participation of civil society, special interest groups, local and international organizations. The financial and technical support of development partners during the process, including the donor community, the UN partners – in particular the support of World Health Organization, is also appreciated. We were able to move along with this plan at a very fast pace because we had strong commitment and the backing of the Ministry’s leadership. The unwavering support of the Minister of Health and Sanitation, the Deputy Ministers of Health and Sanitation, the Chief Medical Officer and the Permanent Secretary, made it all possible. As we gear ourselves toward implementation of the plan, I look forward to many joint missions to implementation sites so we can hold each other accountable for delivering the promises we make in this plan and other Ministry policy documents. I look forward to all of us working together to improve the health of the nation. ____________________________Dr Samuel A.S KargboDirector: Health Systems, Policy, Planning & InformationMinistry of Health and SanitationACRONYMSANCAnte-Natal CareBEmONCBasic Emergency Obstetric and Newborn CareBPEHSBasic Package of Essential Health ServicesCEmONCComprehensive Emergency Obstetric and Newborn CareCHCCommunity Health CentersCHOCommunity Health OfficerCHPCommunity Health PostCHWCommunity Health WorkerCPDContinuing Professional DevelopmentDHMTDistrict Health Management TeamDHSDemographic and Health SurveyEMLEssential Medicines ListEVDEbola Virus DiseaseFHCIFree Health Care InitiativeHCWMHealth Care Waste ManagementHMISHealth Management Information SystemHRHHuman Resources for HealthHSCCHealth Sector Coordinating CommitteeHSSGHealth Sector Steering GroupiCCMIntegrated Community Case ManagementIDSRIntegrated Disease Surveillance & ResponseIHRISIntegrated Human Resource Information SystemIPCInfection Prevention and ControlIYCFInfant and Young Child FeedingJPWFJoint Program of Work and FundingLMISLogistics Management Information SystemMCHMaternal and Child HealthMDGMillennium Development GoalMoHSMinistry of Health and SanitationNHSSPNational Health Sector Strategic PlanSARAService Availability and Readiness AssessmentSECHNSenior Enrolled Community Health NurseSLA (s)Service Level Agreement(s)SLeSHISierra Leone Social Health InsuranceUNDPUnited Nations Development ProgrammeUNICEFUnited Nations Children’s FundUNFPAUnited Nations Population FundWHOWorld Health Organization EXECUTIVE SUMMARYHealth care in Sierra Leone is provided through three levels of care. At the Primary level, the Community Health Worker Programme provide basic prevention and health promotion types of interventions with linkages to the Peripheral health Units at the second level. The third is the hospital level, where both secondary and limited tertiary care is provided. Up to 80% of health care facilities in the country provide Primary Health Care services. Sierra Leone’s first cases of Ebola Virus Disease (EVD) occurred in the eastern part of the country and increased in number and distribution, affecting all 14 districts and outpacing morbidity and mortality in neighbouring Guinea and Liberia. By March 2015, there were more than 8,400 confirmed cases and 3,600 reported deaths, making it the worst affected country in the West African region and in the world. Prior to the EVD outbreak, the health sector had made significant progress in a number of Millennium Development Goals indicators related to health. The country had seen improvement in health coverage, including: (i) an increase from 7% to 16% in modern contraception; (ii) skilled birth attendance improving from 42% to 62%; (iii) Insecticide-Treated Nets increase from 26% to 49%; (iv) Malaria treatment jumped from 6% to 77%; Diarrhoea management improving from 68% to 88% and Basic Immunization increasing from 54% to 78%.Several assessments conducted by the Government of Sierra Leone and/or its partners revealed that the health sector was disproportionally affected by the EVD outbreak. At the sector level, the Ebola epidemic had direct and disproportional effects on the health sector, eroding recent progress towards the Millennium Development Goals (MDGs). As first responders, health workers became infected through the provision of routine care and support to sick patients. Poor early recognition of EVD accompanied by inadequate Infection Prevention and Control (IPC) standards combined to fuel transmission in health facilities. The result was an erosion of community confidence in the sector and a reduction in the delivery of critical maternal and child health services. In the case of nutrition, quarantine restrictions affecting food production and distribution coupled with a deepening of household poverty likely exacerbated acute and chronic undernutrition. Poor early recognition of suspected cases of EVD accompanied by inadequate Infection Prevention and Control (IPC) standards led to a total of 296 EVD infections among health care workers with 221 deaths, including 11 specialized physicians. A reduction in community confidence in the health sector negatively affected utilization – with a 23% drop in institutional deliveries; 39% drop in children treated for malaria; and 21% drop in children receiving basic immunization (penta3). The EVD outbreak also led to the delayed implementation of key health programmes – including critical child health campaigns – as the country’s priorities shifted to focus mainly on the Ebola response. Essential health program management staffs were reassigned to help control the outbreak, campaign-based delivery of essential interventions were halted, and; routine health management and coordination meetings ceased. While the outbreak continues and services remain constrained, there is a high risk of concurrent health vulnerabilities that must be immediately addressed including possible outbreaks of vaccine preventable diseases (particularly measles), a surge in malaria cases and deaths, acute malnutrition, and maternal-newborn deaths due to home deliveries. Estimates suggest post-Ebola levels of under-five mortality have returned to 1990 levels. International support to Sierra Leone played a critical role in addressing major gaps in the response. This included support for physical infrastructure; laboratories with high-level diagnostic capacity; staff training; improved surveillance systems, and; the procurement of supplementary equipment to assist in the response including vehicles, ambulances, phones, computers and other technologies.The country realized that the devastating outcomes of the outbreak was a result of systemic weakness, particularly in the health sector, which could not control and manage the epidemic to prevent further spread and further devastation. Moreover, the health system was constrained with basic services that are directly linked to other sectors, without which, proper response and control measures could not be mounted. For instance, health care facilities needed adequate water supply and power to be able to implement infection prevention and control, hence lack of water and power supply at health facilities meant weak infection prevention and control.The recovery period after the outbreak represents an important opportunity to put Sierra Leone back on-track and strengthen the overall resilience of the health system. The development of the health sector recovery plan started back in November 2014 when the Ministry of Health and Sanitation developed a vision for the health sector. Subsequent events and processes, including consultative forums resulted in the health sector identifying five (5) key priority areas of focus: (1) Patient and Health Worker Safety; (2) Health Workforce; (3) Essential Health Services; (4) Community Ownership; and (5) Information and Surveillance. Using the 5 key priority areas as broad sections, the plan describes key interventions that will be implemented during each of the four phases leading to 2020. The four phases are: (1) Getting to Zero and Transition Phase; (2) Early Recovery Phase; (3) Recovery Phase; and (4) Agenda for Prosperity as a platform for longer term rebuilding of the health system. During the last phase, the health sector will focus on implementing interventions that ensures an enabling environment to deliver the Basic Package of Health Services as revised in 2015. The plan is costed. With support from the World Health Organization (WHO) who conducted the costing exercise, the plan presents three (3) possible scenarios. Under Scenario 1 (Baseline), the consideration is that the health sector continues with business as usual with the coverage for human resources and other inputs as well as the Essential Health Services continuing with the 2014 targets resulting in limited implementation of the basic package of essential health services. With the second scenario (Moderate), In this scenario, the coverage target for human resources and services would be scaled to achieve the pre-EVD levels in 2015 and then increased rapidly to the proposed target by 2020 in alignment with the recovery and resilience strategy of the plan. The third scenario (Aggressive) assumes that implementation scale-up proceeds at a rapid rate initially in order to ensure the rapid reversal of the prevailing impact of EVD on the Health Services, System and Mortality indices of the health sector. The three scenarios have price tags of $583 million, $806 million and $883 million respectively. Following reflection and an internal capacity assessment, the health sector recognizes that it cannot afford to continue with business as usual and that being ambitious will be at the detriment of delivery given the current capacity in-country. Increasing the scale and scope of implementation at a moderate pace seems the most logical approach to achieve the goals and objectives of the health sector recovery plan.At the height of the EVD crisis, Sierra Leone became a spotlight to the international community. As a result, many partners became interested in working with the people of Sierra Leone to fight the outbreak. The health sector expects the spotlight to continue in the aftermath of the EVD and that various kinds of partners will continue to show interest in the health sector. In order to ensure country ownership, a better coordinated approach ad maximized partners support, the Ministry of Health and Sanitation defines the implementation arrangements as part of this health sector recovery plan. The roles of the various players, Government players, development partners (UN and donors); Implementing partners (all categories) as well as Ministry of Health Structures are defined.With a challenging operating environment such as Sierra Leone as well as the global events currently ongoing, the health sector is aware that there is an inherent risk associated with implementing a plan as comprehensive and complex such as this. The health sector recovery plan identifies the envisaged risks and proposes risk mitigation measures to minimize impact. The health sector recovery plan is aligned to the broader national recovery plan that is overseen by the Office of the President. Within the Ministry of Health and Sanitation, a Delivery Operational team was established with strong linkages to the Delivery Team in the Office of the President. The MOHS Delivery Operational Team is tasked with oversight on the implementation of the health sector recovery plan. The immediate tasks of the Team include developing a plan to operationalize the recovery plan as well as a Results and Accountability Framework. The tools will be very critical in monitoring progress towards achievement of the promise as stated in the 6-9 months plan and subsequent implementation phases. The Terms of Reference for the MOHS Delivery Operational Team will initially focus on 6-9 months and will continue to evolve as implementation of the health sector recovery plan progresses. BACKGROUND 1.1 Country Profile The Republic of Sierra Leone is situated on the west coast of Africa, sharing borders with Guinea and Liberia. Its 400km coastline overlooks the North Atlantic Ocean and it has approximately 71,740 sq. km land area. The climate is tropical, with a hot, humid, rainy season from May to October and a dry season from November to April. The estimated population of Sierra Leone is 6.1 million people, of which 40% reside in urban areas. The country is home to about 20 distinct language groups, reflecting a diversity of cultural traditions. Administratively, the country is divided into four major areas, namely Northern, Southern, Eastern regions and the Western area where the capital Freetown is located. The regions are divided into 14 Districts and 149 chiefdoms. There are District Councils consisting of a district chairman, administrators and councilors who administer the districts; while the chiefdoms are governed by locally elected paramount chiefs. With recent decentralization, the country has been divided into 19 local councils that have been further sub-divided into 392 wards. Each ward is headed by an elected councilor.Sierra Leone’s protracted civil conflict, which ended in 2002, eroded vital infrastructure and human capacity. This has resulted in a range of social and economic challenges. The Gross National Income (GNI) per capita (current dollar, purchasing power parity (PPP)) is $1,690 while the GDP growth rate was 6% in 2013. Just 43% of the population older than 15 years are literate, and life expectancy at birth is just 45 years ADDIN EN.CITE <EndNote><Cite><Author>World-Bank</Author><Year>2015</Year><RecNum>3501</RecNum><DisplayText>(World-Bank 2015)</DisplayText><record><rec-number>3501</rec-number><foreign-keys><key app="EN" db-id="29w9e0ta8w0rwbexts3xwzso2a5vaaf55ssv">3501</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>World-Bank</author></authors></contributors><titles><title>World Development Indicators</title></titles><volume> Accessed Feburary 6, 2015</volume><dates><year>2015</year></dates><publisher>World Bank</publisher><urls></urls></record></Cite></EndNote>(World-Bank 2015). The Human Development Index rank for Sierra Leone is 177 out of 187 countries. Total health expenditure is approximately $95 per capita – of which 13% comes from donors, 16% from government, and 76% from private out-of-pocket household contributions ADDIN EN.CITE <EndNote><Cite><Author>WHO</Author><Year>2014</Year><RecNum>3513</RecNum><DisplayText>(Government-of-Sierra-Leone 2010; WHO 2014)</DisplayText><record><rec-number>3513</rec-number><foreign-keys><key app="EN" db-id="29w9e0ta8w0rwbexts3xwzso2a5vaaf55ssv">3513</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>WHO</author></authors></contributors><titles><title>Sierra Leone Country Profile</title></titles><dates><year>2014</year></dates><urls></urls></record></Cite><Cite><Author>Government-of-Sierra-Leone</Author><Year>2010</Year><RecNum>3503</RecNum><record><rec-number>3503</rec-number><foreign-keys><key app="EN" db-id="29w9e0ta8w0rwbexts3xwzso2a5vaaf55ssv">3503</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Government-of-Sierra-Leone</author></authors></contributors><titles><title>National Health Accounts 2007-2010</title></titles><dates><year>2010</year></dates><urls></urls></record></Cite></EndNote>(Government-of-Sierra-Leone 2010; WHO 2014). Government expenditure on health as a percentage of total government expenditure is just 12.3%, approaching the 15% target of the Abuja Declaration. Major external supporters of the health sector include The Global Fund to Fight AIDS, TB and Malaria (The Global Fund), the UK Government (UKAid), European Union (EU), African Development Bank (ADB), and GAVI ADDIN EN.CITE <EndNote><Cite><Author>WHO</Author><Year>2014</Year><RecNum>3513</RecNum><DisplayText>(WHO 2014)</DisplayText><record><rec-number>3513</rec-number><foreign-keys><key app="EN" db-id="29w9e0ta8w0rwbexts3xwzso2a5vaaf55ssv">3513</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>WHO</author></authors></contributors><titles><title>Sierra Leone Country Profile</title></titles><dates><year>2014</year></dates><urls></urls></record></Cite></EndNote>.1.2 Organization of the Sierra Leone’s health systemThe basic organization of the health system is reviewed in other key government documents. Briefly, the core functions of the Ministry of Health and Sanitation at the central level are policy formulation; standards setting and quality assurance; resource mobilization; capacity development and technical support; provision of nationally coordinated services; coordination of health services; monitoring and evaluation of the overall sector performance and trainings. The responsibilities of District Health Management Teams (DHMT) are to implement national health policies and manage health service delivery.Sierra Leone’s health system is comprised of public services, private services that operate on either profit or non-profit basis (e.g., non-governmental organizations (NGOs), including those that are faith-based) and traditional health care. Government run public services account for approximately 80% of health service utilization. The country is served by a network of 1,264 public and private health facilities, including 40 hospitals. The health system is organized into three tiers of care: Peripheral Health Units (PHU) with the extended Community Health Worker (CHW) programme; District Hospitals; and Referral Hospitals. There are a total of 40 hospitals in the country, of which 23 are government owned with the rest owned by private, non-governmental and faith based organizations. Making districts functional and resilient requires a BPEHS that ensures continuum of care for delivery of quality of services – with smooth referral from PHUs to hospitals as needed.The Community Health Workers programme was solidified by the development of a national community health worker policy in 2012. At the time of developing the recovery plan, there was nearly 13,000 CHWs trained and supported by local NGOs. CHWs operate at the community level and provide a range of services including integrated community case management (iCCM), growth monitoring and nutritional counseling, counseling on family planning and distribution of family planning commodities, and other non-clinical services in the country.First line PHUs are further sub-classified into three levels:Maternal and Child Health Posts (MCHPs) are situated at village level for populations of less than 5,000. They are staffed by maternal and child health (MCH) Aides who are trained to provide: antenatal care, supervised deliveries, postnatal care, family planning, growth monitoring and promotion for under-five children, immunisation, health education, management of minor ailments, and referral of cases to the next level. The MCH Aides are supported by a network of volunteer community health workers (CHWs). The updated Basic Package of Essential Health Services (2015) prioritizes improving the quality of health care delivery with special emphasis on high impact maternal and child health interventions and observance of universal precautions. Community Health Posts (CHPs) are at small town level with populations of between 5,000 and 10,000 and are staffed by State Enrolled Community Health Nurses (SECHNs)/Midwife and MCH Aides. They provide the same types of services that are provided at the MCHPs but they also include prevention and control of communicable diseases and rehabilitation. They refer more complicated cases to the next level of health care, the Community Health Centres. Community Health Centres (CHCs) are located at Chiefdom level, usually covering a population ranging from 10,000 to 20,000 and staffed with a Community Health Officer (CHO), SECHN, MCH Aides, an Epidemiological Disease Control Assistant and an Environmental Health Assistant. They provide all the services provided at the CHP level in addition to environmental sanitation and supervise the CHPs and MCHPs within the Chiefdom. At the time of the health sector recovery planning, five CHCs in each district were being upgraded to BEmONC certification.1.3 National Strategies informing the health sector recovery planAligned to the country’s Agenda for Prosperity (A4P), the Ministry of Health and Sanitation, with the support of development partners, has articulated a series of national development plans that outline a Government-led vision with clear commitments for the health sector. Taken together, these are foundational contributions to the Sierra Leone Health Sector Recovery Plan, as they provide overall guidance for health system strengthening and for improving the health, sanitation and nutrition status of the population. Key relevant planning documents that informed this process include:1.3.1 Agenda for Prosperity (2013 – 2018) The Agenda for Prosperity (A4P), Sierra Leone’s third generation poverty reduction strategy paper was developed following an expiration of the Agenda for Change in 2012. This follow on strategy recognized that investing in the health of poor Sierra Leonens, particularly women and children, is a necessary investment in economic and social growth and contributes to the development of Sierra Leone. A4P prioritized strengthening health programmes, introducing new policies and services that will ensure better health outcomes for Sierra Leoneans. In the short term, A4P promised among others, provision of free preventive health services at points of delivery, universal access to family planning and free health care for vulnerable groups. The vision and objectives articulated in the health sector recovery plan are framed around, and aims to deliver on the promise of, the Agenda for Prosperity. 1.3.2 The Basic Package of Essential Health Services (BPEHS, 2010) The BPEHS 2010 specifies a prioritized but limited package of high-impact and cost-effective interventions that should be available to every individual to address the major causes of death and diseases in Sierra Leone. The BPEHS is a critical starting point for this Health Sector Recovery Plan. The BPEHS defines the package of services that should be available at each level of care, and implies that a minimum set of skilled health staff, essential drugs and supplies, and related technical and management competencies will also be present. Finally, it is presented in such a way that costs can be estimated to provide an envelope of required financial resources for service provision.During the process of developing the Health Sector Recovery Plan, technical working groups from the MoHS and partners engaged in a detailed consultation to update the BPEHS. The revisions take stock of pre-Ebola implementation gaps, lessons learned from the epidemic, as well as a wider vision for rebuilding resilience in the sector. This sharpened and revised BPEHS forms the basis of the costing estimates for the Plan moving forward and subsequent implementation. 1.3.3 National Health Sector Strategic Plan (NHSSP 2010-2015) The NHSSP 2010 – 2015 is the current high-level planning document for the health sector. It aims at improving the health of the population in Sierra Leone with special focus on the needs of mothers, children and the poor. Its goal is to reduce inequalities and improve the health status of the people, especially mothers and children, through strengthening the national health system. The NHSSP articulates detailed objectives around the six WHO health system building blocks namely: leadership and governance; service delivery; human re-sources for health; medical products and health technologies; healthcare financing; and health information systems. The general objective of the NHSSP is to strengthen the functions of the national health system of Sierra Leone so as to improve the following performance criteria:Access to health services (improving availability, utilization and timeliness)Quality of health services (improving safety, efficacy and integration)Equity in health services (with focus on disadvantaged groups)Efficiency of service delivery (enhancing value for resources, inclusiveness and strengthening partnerships)The Health Sector Recovery Plan will build on the priorities articulated in the NHSSP, including incorporating lessons learned through the Ebola response. MoHS intends to embark on its second NHSSP (2016 – 2020) building on the Health Sector Recovery Plan subsequently.1.3.4 Free Health Care Initiative (FHCI, 2010) This initiative was introduced in the first year of the National Health Sector Strategic Plan (2010 – 2015) to ensure free preventive and curative health services for pregnant women, lactating mothers and children under five years of age in any Government facility in Sierra Leone as a first step toward universal health coverage attainment. It also augments the support of donors such as the Global Fund in providing malaria testing and treatment services free to the entire population. It recognized that the majority of health care costs in Sierra Leone are borne by households and patients ADDIN EN.CITE <EndNote><Cite><Author>Government-of-Sierra-Leone</Author><Year>2010</Year><RecNum>3503</RecNum><DisplayText>(Government-of-Sierra-Leone 2010)</DisplayText><record><rec-number>3503</rec-number><foreign-keys><key app="EN" db-id="29w9e0ta8w0rwbexts3xwzso2a5vaaf55ssv">3503</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Government-of-Sierra-Leone</author></authors></contributors><titles><title>National Health Accounts 2007-2010</title></titles><dates><year>2010</year></dates><urls></urls></record></Cite></EndNote>(Government-of-Sierra-Leone 2010). The benefits after implementation were direct and immediate, with major gains in utilization and coverage with basic services including immunization, antenatal care and facility delivery ADDIN EN.CITE <EndNote><Cite><Author>Ministry-of-Health-and-Sanitation</Author><Year>2011</Year><RecNum>3529</RecNum><DisplayText>(Ministry-of-Health-and-Sanitation 2011; Diaz, George et al. 2013)</DisplayText><record><rec-number>3529</rec-number><foreign-keys><key app="EN" db-id="29w9e0ta8w0rwbexts3xwzso2a5vaaf55ssv">3529</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Ministry-of-Health-and-Sanitation</author></authors></contributors><titles><title>Free Health Care Initiative Report: April 2010-March 2011</title></titles><volume>2</volume><num-vols>3</num-vols><dates><year>2011</year></dates><urls></urls></record></Cite><Cite><Author>Diaz</Author><Year>2013</Year><RecNum>3531</RecNum><record><rec-number>3531</rec-number><foreign-keys><key app="EN" db-id="29w9e0ta8w0rwbexts3xwzso2a5vaaf55ssv">3531</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Diaz, T.</author><author>George, A.S.</author><author>Rao, S.R.</author><author>Bangura, P.S.</author><author>Baimba, J.B.</author><author>McMahon, S.A.</author><author>Kabano, A.</author></authors></contributors><titles><title>Healthcare seeking for diarrhoea, malaria and pneumonia among children in four poor rural districts in Sierra Leone in the context of free health care: results of a cross-sectional survey</title><secondary-title>BMC Public Health</secondary-title></titles><periodical><full-title>BMC Public Health</full-title></periodical><volume>13</volume><number>doi:10.1186/1471-2458-13-157</number><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>(Ministry-of-Health-and-Sanitation 2011; Diaz, George et al. 2013). However, critical shortages in human resources and drug supply, which characterize many Government health facilities, have made it difficult for the health system to meet the increased demand for services generated by the FHCI. In practice, many women and girls attending health facilities still lack access to drugs and care when they are pregnant ADDIN EN.CITE <EndNote><Cite><Author>Amnesty-International</Author><Year>2011</Year><RecNum>3530</RecNum><DisplayText>(Amnesty-International 2011)</DisplayText><record><rec-number>3530</rec-number><foreign-keys><key app="EN" db-id="29w9e0ta8w0rwbexts3xwzso2a5vaaf55ssv">3530</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Amnesty-International</author></authors></contributors><titles><title>At a crossroads: Sierra Leone's Free Health Care Policy</title></titles><dates><year>2011</year></dates><urls></urls></record></Cite></EndNote>(Amnesty-International 2011).This FHCI and measures to improve its implementation will continue to underpin the Health Sector Recovery Plan. There is a need to continue strengthening existing policies to address non-financial barriers to access. There is also a need to provide health financing alternatives to out-of-pocket expenditures to include a larger proportion of the population. The 2013 National Health Accounts (NHA) still shows a large burden on families to carry the cost of health care, recorded at nearly 60%.1.3.5 Joint Program of Work and Funding (JPWF, 2012-2014) This was developed to operationalize the NHSSP (2010 – 2015) and it was a multi-year framework that aligns interventions to key sector priorities, as well as planning, monitoring and budgeting processes. It is a Medium-Term Expenditure Framework intended to provide a basis for harmonization of work plans and alignment of stakeholder activities to Government priorities. The JPWF was costed at US$473m (average per capita US$25.50 per year). The Government of Sierra Leone committed to contribute 27% of the total cost, and requested financial support from development partners to fill the remaining gap. A review of the JPWF at the end of 2014 showed that only 5% of the plan had been fully implemented in the intended timeframe, while another 25% of the plan had been partially implemented but not completed. It was the first time that the JPWF was reviewed and the lack of monitoring of its implementation has been noted for improvement in future plans.1.3.6 National Health Compact (2011) In line with the International Health Partnerships+ principles, the National Health Compact is a framework outlining roles and responsibilities of the Government of Sierra Leone and its partners regarding implementation of the NHSSP (2010 – 2015), JPWF (2012 – 2014) and BPEHS (2010). The compact outlines the rules of engagement for partners who want to contribute to the health sector. It affirms national ownership of the health sector strategy and implementation; states that development partners will support planning and implementation (particularly financing and work plans) in alignment with and under the leadership and governance of the Government of Sierra Leone. All stakeholders wishing to work in the health sector are expected to agree to the compact to ensure productive working relationships and effective coordination and governance of the health sector. This agreement has further implications for issues around procurement and supply chain management, supervision, monitoring and evaluation, health financing and financial management, as well as human resources. The compact was signed by the representatives of major donor Governments including letters of support by the Global Fund and JICA, the Country Representatives of all UN agencies supporting the health sector, a representative of faith-based groups, a representative of NGOs, and a representative of civil society. Implementation of the health compact is not systematically monitored, in particular, to gauge whether or not the Government and the development partners stay true to their commitments and the principles contained in the IHP+, the basis for the health compact. There are plans to improve monitoring of the implementation of the health compact in future. Health policies, programmes and coordinating structures, such as the Health Sector Coordinating Committee (HSCC), chaired by the Minister of Health and Sanitation with membership from Government and development partners – play an important role in galvanizing cooperation among health and development partners in the country. The HSCC is supported by the Health Sector Steering Group, the technical body that perform analytical work and present policy and strategic documents to HSCC for endorsement.1.3.7 Results and Accountability Framework 2010-2015 (2011) The Results and Accountability Framework articulates the monitoring and evaluation requirements to support health services management and how to engage stakeholders in understanding progress in health programme implementation, and using information for evidence-based decision making. The Framework is organized around the same six pillars as the NHSSP (2010 – 2015): governance, service delivery, human resources, health care financing, medical products and technologies, and health information. A set of indicators with clear targets have been defined for inputs, outputs, outcomes and impacts within the different pillars drawing from a range of existing data sources: Health Management Information Systems (HMIS), heath facility surveys, population-based surveys, Logistics Management Information Systems (LMIS), National Health Accounts, Human Resource Management Information System (HRMIS), Civil Registration, and Human Resource Information Systems (HRIS). The Framework will be revised to incorporate the Health Sector Recovery Plan and subsequently the second National Health Sector Strategic Plan (2016 – 2020).SITUATION ANALYSISIn May 2014, Sierra Leone experienced its first cases of Ebola Virus Disease (EVD) in the remote eastern part of the country at its intersection with Guinea and Liberia ADDIN EN.CITE <EndNote><Cite><Author>Dixon</Author><Year>2014</Year><RecNum>3490</RecNum><DisplayText>(Dixon and Schafer 2014)</DisplayText><record><rec-number>3490</rec-number><foreign-keys><key app="EN" db-id="29w9e0ta8w0rwbexts3xwzso2a5vaaf55ssv">3490</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dixon, M.G.</author><author>Schafer, I.J.</author></authors></contributors><titles><title>Ebola Viral Disease Outbreak - West Africa 2014</title><secondary-title>Morbidity and Mortality Weekly Report</secondary-title></titles><periodical><full-title>Morbidity and Mortality Weekly Report</full-title></periodical><pages>548-551</pages><volume>63</volume><number>25</number><dates><year>2014</year></dates><urls></urls></record></Cite></EndNote>(Dixon and Schafer 2014). The outbreak quickly progressed from a localized to a generalized epidemic, shifting from the sparsely populated east to more densely-settled urban and peri-urban areas in the West. By March 2015, more than 8,400 confirmed cases and 3,600 deaths had been recorded, making Sierra Leone the worst affected country in West Africa and the world. The impact of the epidemic at the macro level is yet to be determined. In providing a snapshot of the situation, the situation of the health sector before the Ebola outbreak is presented, followed by the impact of EVD outbreak on the health system, in particular the impact on health service coverage. 2.1 Status of the health sector prior to EVD outbreakPrior to Ebola, the country had made substantial progress towards a number of the Millennium Development Goal (MDG) targets related to health. Based on the results of the preceding two Demographic and Health Surveys (DHS 2008, 2013) there has been notable coverage gains in access to essential services – including modern contraception (7% to 16%), skilled birth attendance (42% to 62%), malaria bednet utilization (26% to 49%), malaria treatment (6% to 77%), diarrhea management (68% to 88%) and basic immunization (DPT3 54% to 78%),. The recent National Nutrition Survey (2014) also demonstrated that there had been a steady progress towards reducing undernutrition. Between 2008 and 2014, levels of stunting among children under five have been reduced from 37% to 29%, and wasting from 10% to 5% ADDIN EN.CITE <EndNote><Cite><Author>UNICEF-Irish-Aid-and-Ministry-of-Health-and-Sanitation</Author><Year>2014</Year><RecNum>3511</RecNum><DisplayText>(UNICEF-Irish-Aid-and-Ministry-of-Health-and-Sanitation 2014)</DisplayText><record><rec-number>3511</rec-number><foreign-keys><key app="EN" db-id="29w9e0ta8w0rwbexts3xwzso2a5vaaf55ssv">3511</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>UNICEF-Irish-Aid-and-Ministry-of-Health-and-Sanitation</author></authors></contributors><titles><title>Sierra Leone National Nutrition Survey</title></titles><dates><year>2014</year></dates><urls></urls></record></Cite></EndNote>(UNICEF-Irish-Aid-and-Ministry-of-Health-and-Sanitation 2014). The national nutrition program in Sierra Leone, through the MoHS Food and Nutrition Directorate and with the support of partners, has worked extensively to improve infant and young child feeding practices (IYCF). Virtually all babies born in the country are breastfed, with the median duration for all breastfeeding at 19.8 months. However, the median duration of exclusive breastfeeding is only 0.6 months. Levels of anemia are high (79.9%), and only half of children regularly consume foods rich in Vitamin A.Despite encouraging gains, levels of child and maternal mortality remained intractably high - 156/1000 and 1,165/100,000 respectively. These reflect a range of critical implementation challenges. Sierra Leone faces a critical shortage of health workers. The WHO has determined a critical threshold of 23 doctors, nurses, and midwives per 10,000 population for the health workforce to be able to provide the minimal levels of basic skilled care for pregnant women and children. Countries that fall below this threshold will struggle to provide the skilled services required to improve the status of maternal and child health, and are likely to suffer higher levels of maternal and child mortality. As of 2010, Sierra Leone had only 2 skilled providers per 10,000 population, and the country ranked fourth from the bottom of a list of 49 priority low-and-middle-income countries for health worker-to-population ratios,. Based on the recent Human Resources for Health Strategic Plan, 64% of skilled health worker posts are currently vacant. The availability of funds remains a major challenge to filling vacancies, with large numbers of recent graduates staffing health facilities in a voluntary capacity. To address urgent shortages, a national community health worker policy was established in 2012, with nearly 13,000 CHWs trained and supported by local and international NGOs to provide a range of services including integrated community case management (iCCM), growth monitoring and nutritional counseling, counseling on family planning and distribution of family planning commodities, and other non-clinical services in the country. However, these staff operates on a volunteer basis and is not formally part of the health sector human resource establishment - an issue that will need to be taken into consideration.The distribution and skill sets of health professionals were far from being adequate. Presently, 50% of all health professionals are concentrated in the country’s capital of Freetown, serving just 16% of the population. There are only one hundred and eighty five (185) doctors in-post in the entire country ADDIN EN.CITE <EndNote><Cite><Author>Ministry-of-Health-and-Sanitation</Author><Year>2012</Year><RecNum>3532</RecNum><DisplayText>(Ministry-of-Health-and-Sanitation 2012)</DisplayText><record><rec-number>3532</rec-number><foreign-keys><key app="EN" db-id="29w9e0ta8w0rwbexts3xwzso2a5vaaf55ssv">3532</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Ministry-of-Health-and-Sanitation</author></authors></contributors><titles><title>Human Resources for Health Stratetgic Plan 2012-2016</title></titles><dates><year>2012</year></dates><urls></urls></record></Cite></EndNote>(Ministry-of-Health-and-Sanitation 2012). No post-graduate training program exists for medical practitioners, thus graduates who want to specialize are forced to leave the country to pursue further education, and many never return. The health workforce is currently dominated by auxiliary level workers – MCH Aides and CHOs. While development of these cadres has gone a long way towards improving basic primary care at community and PHUs, there remains a critical need to deploy skilled manpower to attain MDGs and build a resilient system. There is also limited structured in-service training and no continuing professional development program for health care workers at all levels. Optimizing quality of care remained a persistent challenge. While 90% of health facilities provide MCH services, the quality of these services remains sub-optimal. Only 1% of health facilities had basic amenities, including standard measures for ensuring patient safety. Just 35% of facilities had basic equipment required for service delivery. Despite a recent effort to strengthen 13 hospitals and 65 CHCs nationwide and upgrade them to EmONC status, an assessment conducted in July 2014 suggested not a single facility had been sufficiently upgraded to meet standards across the seven domains assessed – with a lack of necessary equipment, staffing, supplies, water and sanitation noted as frequent obstacles. The ability of the health information system to inform decision-making was also faced with a range of challenges,. Although districts collect data from health facilities monthly on services provided and utilization of drugs and supplies, the timeliness and completeness of these reports is variable. When district reports are submitted to the central level, they are not consistently entered into the national database, and the MoHS often struggles to provide relevant national- or district-level data on demand. Finally, data from hospitals are not yet captured in the system.Prior to the EVD epidemic, laboratory infrastructure and capacity was largely inadequate, making a limited contribution to diagnosis and patient management, disease surveillance, or outbreak investigation. Appropriate equipment and supplies were general lacking, and bio-safety and bio-security practices virtually non-existent, thereby presenting a serious risk to the staff and the environment. Only one adequately equipped laboratory was available in the country. This number has increased during the current Ebola outbreak, but sustainability of the additional laboratories remains to be seen. At the peripheral level, while 94% of facilities can diagnose malaria, only half have HIV diagnostic capacity and one third can conduct a urine test to confirm pregnancy.Finally, despite efforts under the Free Health Care Initiative, essential medicines remained scarce, particularly at PHUs. Stock-outs of essential medicines occur far too frequently. A recent survey noted an average of just 28% of 14 tracer medicines were available at the time of assessment, with just 1% of facilities having the full list in stock. When limited to the availability of the five national priority medicines, only 17% had all in stock with average availability of 71% ADDIN EN.CITE <EndNote><Cite><Author>WHO</Author><Year>2012</Year><RecNum>3507</RecNum><DisplayText>(WHO 2012)</DisplayText><record><rec-number>3507</rec-number><foreign-keys><key app="EN" db-id="29w9e0ta8w0rwbexts3xwzso2a5vaaf55ssv">3507</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>WHO</author></authors></contributors><titles><title>Service Availability and Readiness Assessment: Sierra Leone</title></titles><dates><year>2012</year></dates><publisher>WHO</publisher><urls></urls></record></Cite></EndNote>. Supply chain management is based on a ‘push’ system in which the quantities of drugs and supplies provided to facilities is determined based on population-level disease burden projections and past health information system data (the quality of which is largely questionable). A more effective supply chain management system would be a ‘pull’ system in which facilities report regularly on their usage and stock levels, and a threshold minimum stock level triggers a resupply as needed, before stock-outs occur. However the reporting and documentation system currently in use in the country is not sufficient to support this transition. A National Pharmaceuticals Procurement Unit (NPPU) was established with a wide procurement and supply chain strengthening mandate. However, the unit has faced challenges in starting up, including donors being unwilling to commit funds to an unproven system, and the recruitment of skilled personnel. Due to these constraints, the unit has been temporarily suspended until appropriate and adequate funding and personnel can be identified, thus it is not currently operating.In summary, the health sector of Sierra Leone should be viewed within the broad historical, socio-economic and geo-political context of high rates of poverty and illiteracy; a country still in the process of recovery from crises including the civil war (1990-2002); the cholera epidemic (2012); and currently the EVD outbreak (2014-present).2.2 Impact of Ebola on the health sectorSierra Leone epidemiological reports show that the number of EVD cases and widespread distribution across all 14 districts from May 2014 onwards was unprecedented – outpacing morbidity and mortality figures of neighbouring Guinea and Liberia. By March 2015, the country had witnessed 8,300 confirmed cases and 3,180 deaths. Evidence shows that lack of infection prevention and control measures contributed to the rapid spread of Ebola. The health and sanitation sector experienced a range of direct and indirect effects as a result of the epidemic, with the potential to reverse recent progress towards the MDG targets. These are summarized below.Human assets: Health workers responding to the Ebola crisis were uniquely affected by the epidemic given their high risk of exposure and infection through routine service delivery. By January 2015, a total of 296 health care workers are known to have been infected with EVD with 221 deaths, including 11 specialized physicians ADDIN EN.CITE <EndNote><Cite><Author>WHO</Author><Year>2015</Year><RecNum>3498</RecNum><DisplayText>(WHO 2015)</DisplayText><record><rec-number>3498</rec-number><foreign-keys><key app="EN" db-id="29w9e0ta8w0rwbexts3xwzso2a5vaaf55ssv">3498</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>WHO</author></authors></contributors><titles><title>Ebola Situation Report - January 14, 2015</title></titles><volume>; Accessed January 24, 2015</volume><dates><year>2015</year></dates><pub-location>Geneva</pub-location><publisher>WHO</publisher><urls></urls></record></Cite></EndNote>. This critical loss of front-line health workers has exacerbated already inadequate human resources for health. Improving the number and capacity of the skilled health workforce is a central priority for the post-Ebola recovery period.To fill the gap, many international health workers have rotated through the Ebola Treatment Units (ETUs), sponsored by a variety of international NGOs and donor governments. This infusion of human resources has been crucial in turning the tide of the outbreak. As this temporary assistance expires, the government of Sierra Leone will work to secure short- to medium-term extensions of the international support while the national human resource capacity is strengthened as a longer term strategy.Service delivery: Since the EVD outbreak, a survey conducted in October 2014 among 1,185 PHUs in Sierra Leone, noted that 47 (4%) were closed at the time of assessment, with a similar number reporting temporary closure since the start of the epidemic. Although 96% of PHUs remain operational, the country recorded a 23% drop in institutional deliveries; 39% drop in children treated for malaria; and 21% drop in children receiving basic immunization (penta3). The EVD outbreak has led to a decline in the utilization of health care facilities for non-Ebola related health needs, particularly in urban areas such as Freetown with a much lower proportion of women reporting pregnancy-related care and as much as a 90% drop in family planning visits. The decline in utilization of health services is due to a number of factors such as: the absence of trusted health staff; loss of confidence by communities in the health system (as non-Ebola cases would mingle with Ebola cases); and safety-related reasons. While the outbreak continues and services remain constrained, there is a high risk of concurrent health vulnerabilities including possible outbreaks of vaccine preventable diseases (particularly measles), a surge in malaria cases and deaths, acute malnutrition, and maternal-newborn deaths due to home deliveries. Infrastructure, supplies and equipment: The EVD outbreak has facilitated a swift influx of infrastructure construction projects. With support from the British government, 11 new hospitals have been constructed with a combined total of over 700 additional treatment beds. Four new reference laboratories have also been established with high-level diagnostic capacity. As the epidemic recedes, there is a danger that these new assets will be lost. Large quantities of highly skilled staff have been brought in to run these facilities during the outbreak; most of these will leave as the need diminishes, and sustainability of supplies and resources for the facilities and labs to remain functional is not ernance: Following the WHO’s declaration of the EVD outbreak as a public health emergency of international concern and the subsequent declaration of a state of emergency by the President - His Excellency Dr Ernest Bai Koroma, the country’s priorities shifted to focus on the Ebola response. Initially overseen by the MoHS, the Ebola outbreak resulted in: (1) reassignment of essential health program management staff to help control the outbreak; (2) suspension of routine health management and coordination meetings. Both policy actions diverted usual critical strategic direction and implementation guidance from routine services to EVD outbreak management. The consequence has been delayed implementation of key health programs. This increased engagement of the country’s leadership and redeployment of key staff to support the Ebola response potentially contributed to management gaps that adversely affected the delivery of routine services in the health and sanitation sector. FROM VISION TO RECOVERY PLANNINGBased on the findings of the Situation Analysis, it was befitting that the intention of the health sector recovery plan is not to return to the situation before Ebola, but to significantly improve the health system to ensure that the vulnerabilities that led to the rapid spread of Ebola Virus Disease outbreak are addressed and that we are better prepared for future potential threats. The leadership of His Excellency, the President of the Republic of Sierra Leone, Dr Ernest Bai Koroma which included his decision to declare a state of emergency and an appeal for both local and international support to combat the EVD outbreak, proved to be of significant importance in the fight again the deadly viral disease. It led to subsequent commitment among all stakeholders – including the Government of Sierra Leone, the national and international communities to mobilize resources and mount a comprehensive response to the EVD outbreak. Before the country understood the magnitude of the consequences of the EVD outbreak, leading the war against Ebola was assigned to the Ministry of Health and Sanitation. When it became clear that the EVD outbreak posed a bigger and much more complex challenge with consequences reaching far beyond the health sector, not only did the President establish a National Ebola Response Centre (NERC) but he also took over as Chair of a high level forum that provided a roadmap for eliminating EVD in the country. His vision was to win a war against the outbreak and return to the development path that saw Sierra Leone become one of the fastest growing economies in the world. This development freed up time and provided space for the Ministry of Health and Sanitation to critically analyze the health system, its weakness prior to EVD outbreak, the impact of the EVD on the health sector and begin to develop a roadmap to health sector recovery. The health sector recovery plan is framed around the vision of the Ministry of Health and Sanitation and is aligned with the broader national rebuilding efforts across the various sectors. Investment in this plan will contribute to the development of Sierra Leone as articulated in the Agenda for Prosperity. As Ebola recedes, many key actors including the government, development partners, and civil society are actively contributing towards recovery phase planning efforts. This represents an opportunity to ‘build back better’ – to draw from the learning and capacity generated from the Ebola response to identify and address critical gaps in the health and nutrition sectors. The expected outcome of health system recovery includes the immediate resumption of routine and ‘catch-up’ activities; the accelerated implementation of the Basic Package of Essential Health Services (BPEHS) and; focused efforts to identify and address health system vulnerabilities that led to the unprecedented EVD outbreak. In November 2014, the Ministry of Health and Sanitation (MoHS), Sierra Leone and the United Nations agencies, including the World Health Organization (WHO) and United Nations Children’s Fund (Unicef), separately and jointly conducted a series of assessments of the country’s health system using approaches that combined facility surveys; district, hospital and facility field visits; issue analyses; prioritization meetings; stakeholder consultations and dialogues. The outcomes of these assessments partly informed the vision of the Ministry of Health and Sanitation developed in early December 2014. On 04 December 2014, the Minister of Health and Sanitation presented the vision of the Ministry of Health and Sanitation to the Health Sector Coordinating Committee (HSCC) which is to “build functional and resilient national and sub-national health systems that deliver safe, efficient and high quality health care services that are accessible, equitable and affordable for all Sierra Leoneans”. The intention is to contribute to the socio-economic development for the Sierra Leonean population as articulated in the Agenda for Prosperity. Subsequent forums took place locally and internationally and all helped to refine the Ministry’s thinking. In Mid-December 2014, a High level meeting on building resilient systems for health in Ebola-affected countries, 10-11 December 2014, Geneva, Switzerland where Sierra Leone was represented by the Minster of Health and Sanitation and one representative from the local faith based organizations. The high level meeting was followed by a Technical Working Meeting: Building resilient health systems in Ebola-affected countries, on 12 December 2014, Geneva, Switzerland where Sierra Leone was represented by the representative of the local faith based organizations. It was at the follow up technical meeting that a health system recovery and resilience investment framework for the three Ebola-affected countries was developed. To ensure contribution of the Government of Sierra Leone to the framework, a small team consisting of MOHS technical teams and WHO country office staff met to refine the investment framework, contextualizing it to Sierra Leone and substantiating the key strategies. In late December 2014, HSCC chaired by the Minister of Health and Sanitation, endorsed the refined investment framework. The investment framework (Figure 1) consists of expected key results, key priority areas of focus and the expected outputs. The key result areas and strategies formed the basis for reconstituting the Health Sector Steering Group (HSSG) into five working groups, namely: 1) Patient and health worker safety; 2) Health workforce; 3) Essential health services; 4) Community ownership; and 5) Information and surveillance. The Ministry of Health and Sanitation sees the Basic Package of Essential Health Services (BPEHS) as the vehicle for delivering the promise of accessible, equitable and affordable health care services for Sierra Leoneans. Addressing the gaps in implementation of the BPEHS will ensure expansion of the Free Health Care Initiative (FHCI) across all levels of care. The Ministry is also cognizant of the need for significant support from partners. Therefore, the ideals of the Health Compact signed by all HSCC members in 2010 are emphasized, with particular attention drawn to the areas of national ownership and mutual accountability. In January 2015, a multi-stakeholder Consultation on building a resilient system for health in Sierra Leone was convened with 196 participants representing the MOHS, Sierra Leone (88); district councils (12); district management offices and medical superintendents (18); UN and donor partners (32); and civil society, international and local NGOs (46). The consultation was a key interim milestone achieved in the overall implementation of a roadmap to development of a country plan for health systems resilience. In line with the objectives for convening the meeting, the consultation delivered the following: 1) consensus on the situational analysis and identified strategies for recovery and building a resilient system for health in Sierra Leone; 2) agreement on lessons learned and recommendations from a review of the implementation of the ongoing JPWF; 3) draft means of operationalizing a recovery plan through the BPEHS; and 4) next steps in developing and finalizing the health system recovery and resilience plan. The consultation conveyed two general key messages: 1) the EVD outbreak is both an unprecedented health crisis and presents a huge opportunity for health system strengthening; and 2) the efforts to recover must begin early and run parallel to the fight to end Ebola and reach zero cases. In moving forward towards drafting and finalization of a costed, multi-year recovery plan for Sierra Leone, stakeholders at the consultation agreed on the following:National health system recovery and resilience would be attained and sustained by making every district functional and resilient; The utilization of the BPEHS in recovery planning and its full implementation afterwards would be important; andThe continuation of an inclusive, intersectoral action for health guided by the leadership of the Ministry of Health and Sanitation with support from the leadership of the country compact signatories would be crucial in paving the transition and restoration of essential health services. There has to be a coherent and optimal use of current available resources in the country.This meeting was followed by updating and costing the BPEHS and the development of the district plans, which serves as the basis for the Sierra Leone Health Sector Recovery Plan. A summary of key events that took place in developing the health sector recovery plan is found in Annex 1. THE HEALTH SECTOR RECOVERY FRAMEWORKThe Ministry of Health and Sanitation and its partners developed a health sector recovery framework (Figure 1) which formed the basis of the recovery plan development. The Key Principles of the Health Sector Recovery Framework are: Establish safe and healthy work settings;Increase district/facility skilled workforce with emphasis on underserved areas;Make essential (basic) health services available;Foster communities that engage the health system to improve trust, take ownership of their own health, demands accountability, and access essential health services;Improve health system governance processes and standard operating procedures; andInternational Health Regulations (IHR) compliance.Using the BPEHS as the cornerstone of the health sector recovery plan made it necessary to revise the BPEHS to ensure that it can fulfil the objectives and the ideals of the recovery plan. The health sector is fully aware that recovery will not be achieved overnight and that it will not be possible to implement all interventions at once. Therefore, the sector worked on sequencing of interventions. 4.1 Key Priority AreasDevelopment of the framework was informed by the technical meeting in Geneva; a follow up meeting to the high level meeting that took place in Geneva in December 2014. It was further refined at the country level following significant consultations with stakeholders including Government of Sierra Leone and health development partners. This medium-term framework forms the basis of a costed strategy to strengthen the health sector by making every district functional and resilient, with a particular focus on five Key Priority Areas: (1) Patient and Health Worker safety; (2) Health workforce; (3) Essential health services; (4) Community ownership; and (5) Information and surveillanceUnderpinning the five key priority areas are cross cutting focus areas that ensures a conducive operational environment and these are: (1) Leadership and Governance; (2) Efficient health care financing; and (3) Cross-sectoral collaborations. 4.2 Basic Package for Essential Health Services (2015)The 2010 version of the Basic Package of Essential Health Services was not adequate to propel the health sector to achieve the aims and objectives of the health sector recovery plan by 2020. The health sector revised the Basic Package for Essential Health Services to clearly articulate the services that Sierra Leoneans can expect at the various levels of care (community, MCHP, CHP, CHCs, district and regional hospitals) as well as the required inputs (human resources, equipment, drugs, supplies and material) to be enables the various levels to deliver the services promised. The revised Basic Package for Essential Health Services can be accessed as a separate document to this health sector recovery plan. -42262228890Key Expected Results Safe and healthy work settingsAdequate Human Resources for HealthEssential (basic) health and sanitation services are availableCommunities able to trust the health system and access essential health servicesCommunities able to effectively communicate and effectively send health alertsImproved health system governance processes and standard operating proceduresInternational Health Regulations (IHR) followed00Key Expected Results Safe and healthy work settingsAdequate Human Resources for HealthEssential (basic) health and sanitation services are availableCommunities able to trust the health system and access essential health servicesCommunities able to effectively communicate and effectively send health alertsImproved health system governance processes and standard operating proceduresInternational Health Regulations (IHR) followed-4095755431790Figure 1: The health sector recovery frameworkFigure 1: The health sector recovery framework-4267204869815Enabling Environment: (i) Leadership & Governance; (ii) Efficient Health Care Financing Mechanism; and (iii) Cross-Sectoral Synergies.00Enabling Environment: (i) Leadership & Governance; (ii) Efficient Health Care Financing Mechanism; and (iii) Cross-Sectoral Synergies.71380352364740Information & SurveillanceDisease surveillance & databaseDistrict health information system (DHIS2)Human Resource information system (HRIS)Logistics Management Information System (LMIS)Burden of disease studiesNational Health Accounts00Information & SurveillanceDisease surveillance & databaseDistrict health information system (DHIS2)Human Resource information system (HRIS)Logistics Management Information System (LMIS)Burden of disease studiesNational Health Accounts7899400208216555016402363470Community OwnershipRevise policy and guidelines on Community leadership Community dialogue Community-based approaches Linkages between facility and communityImprove community initiated health alerts 00Community OwnershipRevise policy and guidelines on Community leadership Community dialogue Community-based approaches Linkages between facility and communityImprove community initiated health alerts 31883352363470Essential Health ServicesIntegrated Management of Childhood IllnessCore malaria control interventions, including HIV/AIDS and TBMaternal & Child life-saving interventionsTeenage Pregnancy preventionNon-Communicable DiseasesEssential Medicines & Supplies including PPEsImprove referral including revitalization of the national ambulance serviceDiagnostic laboratories & blood transfusionRehabilitation & facility equippingHealth promotion, environmental health & sanitation 00Essential Health ServicesIntegrated Management of Childhood IllnessCore malaria control interventions, including HIV/AIDS and TBMaternal & Child life-saving interventionsTeenage Pregnancy preventionNon-Communicable DiseasesEssential Medicines & Supplies including PPEsImprove referral including revitalization of the national ambulance serviceDiagnostic laboratories & blood transfusionRehabilitation & facility equippingHealth promotion, environmental health & sanitation 4197985208470514363702363470Health WorkforceNational & 3 regional referral hubs for quality careEstablish a medical post-graduate centreStrengthen national & 3 regional training institutionsEstablish CPD programmes for all health cadresImproving individual, provider and sector performanceStrengthening ethics and health regulations00Health WorkforceNational & 3 regional referral hubs for quality careEstablish a medical post-graduate centreStrengthen national & 3 regional training institutionsEstablish CPD programmes for all health cadresImproving individual, provider and sector performanceStrengthening ethics and health regulations-4184652364105Patient & Health Worker SafetyPS and health services & systems developmentNational PS policyKnowledge & learning in PSPS awareness raisingHealth care-associated infectionsHealth workforce protectionHealth care waste managementSafe surgical careMedication safetyPS partnershipsPS FundingPS surveillance & research00Patient & Health Worker SafetyPS and health services & systems developmentNational PS policyKnowledge & learning in PSPS awareness raisingHealth care-associated infectionsHealth workforce protectionHealth care waste managementSafe surgical careMedication safetyPS partnershipsPS FundingPS surveillance & research62255402091055215582520891502438402087880128016014097000015055851212215Health Workforce Outputs00Health Workforce Outputs2973070141732000695833014351000055708551227455Community Ownership Outputs00Community Ownership Outputs5269865143256000420052516002000033343851212215Essential Health Services Outputs00Essential Health Services Outputs-4184651824355Sierra Leone Basic Package for Essential Health Services (BPEHS): Full implementation by 202000Sierra Leone Basic Package for Essential Health Services (BPEHS): Full implementation by 2020790321016211550062274451619885002157730156400500257810157480000-4114801206500Patient & Health Worker Safety Outputs00Patient & Health Worker Safety Outputs72809101230630Surveillance & Information Outputs00Surveillance & Information Outputs7903210102997000622871599695000420878010083800021659851007110002451101007110004.3 Sequencing of EventsThe Sierra Leone Health Sector Recovery Plan will be implemented in four inter-related, clearly sequenced yet overlapping phases. Figure 2 below clearly shows that health sector recovery interventions will be implemented incrementally over the next five years and nine months. Below is the description of the four phases.-69215-56300Figure 2: The road to recovery, depicting all phases over 6 years (2015 to 2020)Phase I: The Transition phase or “Getting to Zero” is scheduled to be implemented immediately and lasts until December 2015 (or as may be necessary). As this is the initial phase, the health sector will focus on key interventions that can be implemented with key results demonstrated within the remaining period of 6-9 months. This phase will put a lot of emphasis on getting to zero while initiating some of the transition and early recovery interventions. Two key recovery priorities in the Office of the President will be prioritized and these are: (i) Ensure Patient and Health Worker Safety; and (ii) Restoring the critical elements of the basic package of health services. Phase II: The early recovery phase which begins in mid-2015 overlapping with both the Ebola elimination and the subsequent Recovery phases. During this phase, the health sector will combine a continuation of efforts to sustain zero, accelerate early recovery interventions and establishes a platform for transitioning to the recovery phase.Phase III: The Recovery phase begins halfway through the early recovery phase and continues until end of 2017. Over a period of 3 years (2016 to 2018), some of the early recovery interventions will be reaching full scale while the country embarks on a comprehensive menu of interventions that will ensure full recovery is realized by the end of 2018. It is also during this period that the health sector will gradually begin to fall back on the development path along the frame of the agenda for prosperity. It is at the conclusion of the early recovery and mid-way through the Recovery phase that the health sector will fall back on the Agenda to Prosperity, a key national development policy of the Government of Sierra Leone; andPhase IV: This phase begins in the midst of the Recovery phase and continues for four years. A series of strategic priorities for this time have been identified within the health sector. While the immediate priority will be on eliminating Ebola, implementation for the overall framework for recovery across the five outlined domains has commenced. Over a period of four years, the Ministry of Health and Sanitation, with support from partners, will implement interventions that are geared towards longer term sustainable solutions to the current health care system challenges. By 2020, the basic package of essential health services would have been fully implemented and the health sector along with relevant Government Ministries, Departments and Agencies (MDAs) would have made significant progress with the implementation of the Sierra Leone Social Health Insurance and there will be more options for sustainable health care financing that will usher the country to universal health coverage. At the end of this period, the health system should be expected to withstand all shocks and improve of health related goals and outcomes. Using the five key priority areas as sections, the health sector recovery plan clearly defines interventions that will be implemented during each of the four phases. Table 1: The organization of the health sector recovery plan494347450800Phase IV00Phase IV373380053975Phase III00Phase III252412553976Phase II00Phase II122872553975Phase I00Phase I4943474117475Achieving MOHS vision00Achieving MOHS vision-57151117475Key Priority00Key Priority3733165114300Recovery00Recovery2524125114300EarlyRecovery00EarlyRecovery1228725114300Transition (getting to zero)00Transition (getting to zero)-5778579375Patient & health worker safety00Patient & health worker safety494347572390Interventions to be implemented in the 48 months (4 years)00Interventions to be implemented in the 48 months (4 years)373380072390Interventions to be implemented in the 21 months00Interventions to be implemented in the 21 months252412572390Interventions to be implemented in the 18 months00Interventions to be implemented in the 18 months122872572390Interventions to be implemented in the 6-9 months00Interventions to be implemented in the 6-9 months-5715140640Health Workforce00Health Workforce-571511905Essential Health Services00Essential Health Services-57785754380Information & Surveillance00Information & Surveillance-57785240030Community Ownership00Community OwnershipKEY PRIORITY ONE: PATIENT & HEALTH WORKER SAFETY“We cannot embark on our road to recovery until we get to zero” Minister of Health & Sanitation Dr AB Fofanah, Opening Address at district consultations workshop, 05 March 201531997651254125Key StrategiesEstablish triage procedures for safe essential health services restoration in transition phaseStrengthen infection prevention and control measures00Key StrategiesEstablish triage procedures for safe essential health services restoration in transition phaseStrengthen infection prevention and control measuresOne of the factors that fueled both the Ebola transmission and the loss of health workers has been insufficient guidelines and practice to ensure patient and health worker safety. Addressing these gaps is an immediate priority for the “Getting to Zero” phase of the recovery plan and for strengthening the resilience of the health system in the longer term. Patient safety refers to processes or structures which, when applied, reduce the probability of adverse events resulting from exposure to the health-care system across a range of diseases and procedures. In October 2008, all countries in the WHO African Region agreed upon a framework for patient safety which outlined 12 key priority areas ADDIN EN.CITE <EndNote><Cite><Author>WHO-African-Regional-Office</Author><Year>2008</Year><RecNum>3535</RecNum><DisplayText>(WHO-African-Regional-Office 2008)</DisplayText><record><rec-number>3535</rec-number><foreign-keys><key app="EN" db-id="29w9e0ta8w0rwbexts3xwzso2a5vaaf55ssv">3535</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>WHO-African-Regional-Office</author></authors></contributors><titles><title>Patient safety in African Health Services: Issues and solutions</title></titles><volume>AFR/RC58/8</volume><dates><year>2008</year></dates><pub-location>Yaounde</pub-location><publisher>AFRO</publisher><urls></urls></record></Cite></EndNote>(WHO-African-Regional-Office 2008). 5.1 Getting to Zero and Transition Phase During transition, the health sector will prioritize getting to zero interventions and focus effort on the key priority that will be monitored by the office of the President while implementing other key recovery interventions outside of the President’s programme. The sector will focus on ensuring patient and health worker safety by: Assuring effective IPC at health care facilities;Establishing triage/isolation in all hospitals and CHC including referral capacity;Supporting IPC with improvements to WASH, laundry and waste disposal at facilities; andImplementing a continuous improvement program for IPC.A national policy on infection prevention and control has been developed and it clearly outlines standard operating procedures for patient and health worker safety, in the context of a wider multidisciplinary approach to strengthening the health-care system. The national policy includes norms, standards and codes of ethics on patient safety; guidelines on the appropriate use, quality and safety of medicines; and relevant metrics for monitoring progress towards full implementation. To operationalize the policy, initial emphasis will be placed on following patient and health care workers safety interventions:5.1.1 Establish triage procedures for safe restoration of essential health services Key activities in this component will be completed by end 2015. The triage protocols established in 2015 will be maintained, ensuring implementation and subsequent monitoring at all health facilities, including non-Ebola facilities. Procedures will be regularly monitored and reviewed to ensure high quality standards and sustainability. MoHS will work with UN and development partners to refurbish health facilities, prioritizing hospitals, and improve staffing to ensure health facilities are adequately capacitated to implement triage procedures and adhere to guidelines. 5.1.2 Strengthening Infection Prevention and Control measuresPatient safety awareness: The involvement of patients in campaigning for the development and implementation of safety improvement measures in health care settings is crucial. Sierra Leone currently has no Patient Declaration of Rights Charter. Developing such a charter is an important starting point. This will be adapted to the local languages and displayed at facilities. A situation analysis of patient safety will be conducted, followed by awareness and sensitization efforts regarding patients’ rights and mutual responsibilities regarding health sector safety-related issues. A cadre of ‘district champions’ will be developed to conduct sensitization campaigns and motivate and sustain awareness employing radio, Facility Management Committees and other relevant community forums. Health care-associated infections: Patient and health worker safety can be greatly enhanced through the implementation of simple measures such as improved hygiene conditions, appropriate health care waste management and the safe use of injections, invasive devices & blood transfusions. Hand hygiene has a very high impact on morbidity and mortality and is the most effective infection control measure. It should be promoted as the entry point for subsequently enforcing other essential preventive measures – particularly using alcohol-based hand rub. WHO and partners have published numerous tools & guidelines on management of health care workers, blood safety, injections and hand hygiene. These will be adapted to national contexts and subsequently implemented.Steps to strengthen will complement the support already provided to health workers and facilities in the context of the Ebola epidemic, and will contribute both to EVD elimination as well as longer term resilience. This will include: Comprehensive staff training in IPC standards, adherence and patient safety measures. Nearly 1,200 PHUs have already undergone such training as part of the Ebola responseperiodic monitoring and accreditation of facilities compliance using the WHO’s Service Availability and Readiness Assessment Tool and other relevant assessment modules. Auditing of facilities for IPC adherence has been initiated in the context of the Ebola responseIn addition, reducing health-care associated infections will require health infrastructure improvements and provision of essential equipment and supplies for infection control. At all levels including PHUs, this includes safe and reliable water sources and basic hand washing stations; improved sanitation facilities; electricity and refrigeration facilities; enhanced capacity to perform onsite diagnostic testing, and; equipment such as auto-destruct syringes and sharps boxes. At secondary facilities, additional capacity for safe blood transfusion (available in less than 60% of hospitals), autoclave facilities, and the ability to ensure safe surgical care are required. Health care waste management: Availability in health care settings of safe disposal systems for the secure containment and elimination of contaminated and sharp waste will improve the management of waste in health care settings. Tools and guidelines will be developed relevant to the national context and implemented in order to improve health care waste management. Within each facility, health care workers will be trained on how to sort medical waste according to type and nature. A waste segregation and disposal system will be implemented based on the standard operating procedures. DHMTs will be responsible for monitoring all facilities as part of routine supervisory systems. Health care worker protection through provision of PPE: Provision to health care workers of adequate equipment and commodities (masks, gloves, gowns) will protect them from contact with body fluids. In case of unknown epidemics, personal protective equipment should be provided to health care workers and properly used all the time. Vaccination against hepatitis B virus and other vaccine-preventable pathogens would increase protection. Each facility would be required to operationalize a health care worker protection system including PPE, infection safety and vaccination, with the DHMT’s responsible for monitoring implementation as part of routine supervisory systems.5.2 Early Recovery Phase and beyondInterventions under the Infection Prevention and Control key priority area will be fully implemented during the initial phase of getting to zero. All key interventions implemented during the period “getting to zero and transition” will be maintained throughout the phases. In addition, MOHS and partners will work on comprehensive monitoring of implementation at the facility level will be crucial during the early recovery phase and beyond. The health sector will also identify IPC focal points, one for each district to be part of the DHMT as well as one each per hospital to support the implementation of IPC through supportive supervision and ensuring quality of implementation. KEY PRIORITY TWO: HEALTH WORKFORCE“We have a limited capacity and our health workers are not well prepared” Dr. Brima Kargbo, Sierra Leone’s Chief Medical Officer (copied from WHO website)31318201254125Key StrategiesIncrease district/facility skilled workforce with emphasis on underserved areas and community-based deliveryEstablish and deliver in-service health worker training package on Sierra Leone BPEHSEstablish a local post-graduate medical training programme00Key StrategiesIncrease district/facility skilled workforce with emphasis on underserved areas and community-based deliveryEstablish and deliver in-service health worker training package on Sierra Leone BPEHSEstablish a local post-graduate medical training programmeEffective implementation of Sierra Leone’s BPEHS can only be accomplished with an adequate and skilled health workforce. The country faces a shortage in the absolute number of health workers, inequitable distribution of these staff, and insufficient skill sets to meet the needs of the population. These systemic vulnerabilities carry bidirectional effects. Health system inadequacies limited an effective early response to Ebola, while the epidemic concurrently deepened the crisis within the system, with the loss of over 200 front-line health workers. Conversely, the health system also demonstrated a number of strengths in the face of the Ebola crisis. The vast majority of clinics remained open with health workers continuing to deliver care across a range of high-risk settings. The national and global response also created new opportunities which can be harnessed to support the post-Ebola recovery. Health workers previously serving as volunteers at PHUs were mobilized to support the Ebola response, and many new response workers entered the health system and gained useful skills in disease prevention and control. International teams provided complementary skills in clinical care and disease surveillance alongside capacity development, mentorship and support to national staff. Finally, partners including UN agencies and NGOs expanded their portfolio of staff and services, both for the immediate Ebola response and for longer term support to the MoHS.6.1 Getting to Zero and Transition PhaseThe country is right-sizing the EVD response. An important aspect of this process is the human resources required to manage the remaining 12 centres and maintaining EVD services for the entire country. 6.2 Early Recovery PhaseTaking stock of lessons learned through the Ebola crisis and the challenges outlined above, a series of priority intervention areas have been designed to fast-track key objectives contained in the HRH Strategic Plan (2012-2016).6.2.1 Increase district/facility skilled workforce, emphasizing underserved areas EVD health staff: It is anticipated that the first round of Ebola facility closures undertaken as part of the transition process will affect 40%-50% clinical MoHS staff, 30%-40% skilled volunteer non-MOHS staff and 15%-20% unskilled volunteers. Optimal placement and utilization of these health workers and the mechanisms for their gradual re-profiling and redeployment, including associated implications on payroll are being explored. Discussions have also been initiated on key EVD staff becoming ‘Ebola Champions’, taking on roles with a specific responsibility for strengthening IPC at MoHS facilities. Such ‘Champions’ can also be made available for recall as surge staff, if required. Another main component will be managing the return of medical and nursing students to study programmes when education institutions reopen.Foreign health workforce: Working with the office of the Diaspora in the Office of the President, international agencies and NGOs, MoHS will fast track the recruitment of Sierra Leonean health workers abroad, engage foreign medical teams (FMTs), and laboratory personnel as a matter of urgency to move forward critical areas of support, and strategies for maintaining and expanding the range of services provided. Urgent priorities include IPC training and accreditation; support to community-based surveillance efforts; re-vitalization of primary health infrastructure and services; the development of accredited reference laboratories and expanding decentralized diagnostic and testing capacity, and; training and capacity development through three regional centers of excellence. Options for extension and acquisition of requisite skilled external staff will be explored with the aim of enhancing quality of care and rapids skills transfer. Alongside these efforts, strategies to engage additional available national staff such as retired clinicians and junior workers who supported the Ebola response will be explored. Community health workers: A cadre of 13,000 CHWs already provide a range of preventative and basic curative services throughout the country, including integrated community case management for malaria, diarrhoea and pneumonia. Options to establish a sustainable facility-community interface to maximise on the valuable contribution by this cadre will be explored. Steps to ensure effective monitoring, accreditation, motivation, and continuing education/upskilling will be important to optimize this initiative. The Ministry of Health and Sanitation is in the process of establishing a Community Health Program secretariat under the Directorate of Primary Health Care. HR support in institutionalizing this valuable cadre under the MoHS human resource scheme will be important to ensure their sustainability and integration into the holistic health system and strategy.Review HRH policy and practice including incentive and remuneration packages. In the area of leadership and governance, the MoHS has revisited its management structure, and a revised organogram is under development. The aim is to establish clearly defined roles and responsibilities of personnel within the health sector, including the HRH directorate at the MoHS. Efforts are underway to review and harmonize the various Acts of Parliament (Hospital Board Act, Local Council Act, Professional Bodies and Health Service Commission Act) that impact on health service delivery and quality control. The important role of the Health Services Commission (HSC) has not been adequately supported with resources and capacity over the years In order to fulfil its mandate of improving basic conditions of employment for health workers and speed up absorption of qualifying health workers, the health sector will focus on increasing the capacity of the commission with a purpose of significantly increasing it to better support the MOHS. Other areas related to basic conditions of service - incentive and remuneration packages (e.g., recommendations on administrative versus clinical positions; salary and other conditions of service, including a separate remuneration status for health workers) are being reviewed. This includes defining and agreeing upon what constitutes a 'hard to reach' vs. 'rural' vs. 'remote' facility to determine the appropriate motivational incentives. A simple performance-based financing scheme was introduced prior to the Ebola epidemic. A review of these pilot efforts has been undertaken, and plans to pilot an expanded ‘PBF Plus’ scheme are in motion, to be concluded in 2015 and rolled out national thereafter. Evidence shows this scheme has a positive role to play in motivating health workers, strengthening systems, and improving coverage with essential interventions. 6.2.2 Establish and deliver in-service health worker training on BPEHSThe MoHS will work to improve the quality and capacity of the health workforce through strengthening pre-and in-service training. Regional hubs: As part of the overall strengthening of the health workforce, three regional hubs will be established to serve as centres for excellence that include a critical mass of requisite specialists who will be deployed on an as-needed basis to districts in their coverage area. In 2015, the main focus will be to engage foreign medical teams to staff the regional hubs. It will be important to reach an agreement among all the key actors on the role and functions of these hubs – where possible, the EVD foreign medical teams will be repurposed as the transmission and need for intensive case management is reduced. Care will be taken not to divert EVD case management resources before the outbreak is controlled. The regional hubs will also enhance the referral system as Specialists placed in the regional hospitals receive and manage complicated cases from the lower levels of care. Training on revised BPEHS: The urgent priority in 2015 and early 2016 is to train health workers in the updated priorities and services in the revised BPEHS. The training will be based on a clear set of guidelines and protocols that will accompany the BPEHS and will be delivered at the regional hubs.6.3 Recovery Phase 6.3.1 Update remuneration packages Based on the review of the health worker payroll, and the revised policies, there will be a need to implement new incentive and remuneration mechanisms. This will entail the development of innovative, evidence-based motivational packages to improve health workforce retention. Such measures will include sustainable, long-term prompt payment of salaries while minimizing the funding gaps. Furthermore, findings from the review will also prompt the implementation of updated mechanisms for performance-based financing.6.3.2 Enhance training including at post-graduate levelsNational and regional training institutions (University of Sierra Leone, University of Makeni, Njala University and College of Medicine and Allied Health Sciences (COMAHS)) will be supported to increase the number of graduates each year in accordance to revised draft training plan. Curricula for all professions will be reviewed. The capacity of the existing medical school will be expanded to produce at least 100 students annually. National postgraduate training for all medical and allied health workers, especially for underserved areas and specialties will be enhanced. Special emphasis will be accorded to training of midwives and other paramedical staff training in critical disciplines by public and private sector. In addition, a ‘Direct Entry’ program will be introduced to increase midwife numbers. Finally, in the context of post-Ebola recovery partnerships, bilateral links will be explored to provide support for local and overseas training of health workers (in partnership with sub-regional and international training institutions).Medium-term implementation will include advocating and supporting the approval of the Sierra Leone Postgraduate Colleges of Health Specialties Act and its implementation. Assessment will be conducted to develop an investment plan guided by training plan. The MoHS will also work on the development of a Continuing Professional Development programme and a post-graduate medical training centre to support a self-reliant health system for the country. 6.3.4 Strengthen regional referral hubsBuilding on dialogue between central and district levels and partners, three regional referral hubs established in 2015 will be further developed as centres of excellence to support regional referrals and training needs. Hubs will concentrate health expertise to enable skills transfer, improvements in patient safety, mentoring and coaching for quality of care, the creation of a continuum of care network from community level. Quality of care guidelines will be developed including patient safety with a focus on IPC, along with improved surgical, medical, paediatric and obstetric/gynaecological services, for hospitals, PHUs and community level service delivery. Regional hubs will ensure a critical mass of requisite specialists will be deployed to (i) mentor local practitioners (ii) support quality of care guidelines (iii) contribute towards establishment of a continuing education programme, (iv) coach training institution attached students, (v) contribute towards establishment of a e-health and e-learning platforms, (vi) support establishment of regional laboratory and blood transfusion centres, and (vii) contribute to central level definition of norms and standards. Regional hubs will house training/lecture facilities and also include establishment of functional theatres (including for comprehensive emergency obstetric care), accident and emergency units, regional blood transfusion centres, biomedical and maintenance units, diagnostic units, implementation of surveillance activities, coordination of referral systems and support for ancillary facilities – including mortuary, kitchen, laundry, central sterilization units, adequate waste management). 6.3.5 Strengthening career pathways Mechanisms to strengthen career progression, promotions and mobility of the health workforce across the entire health sector with particular attention to rural and remote areas will be undertaken. A particular focus will be placed on health worker motivation utilizing multiple mechanisms including long distance peer support. The use of institutional health partnerships (between Sierra Leone and other countries both in the African Region and beyond) will be utilized to enhance workforce capacity in specific technical areas. 6.3.6 Continuing professional development (CPD)In order to address skills and competency gaps for effective service delivery, continuing professional education will be established including e-learning harnessing the professional association’s capacity and collaboration. CPD programs will be used to support in-service training and linked to career pathways for all cadres of practitioners.6.3.7 Establishing a local post-graduate medical training MoHS intends to establish a local post-graduate medical training programme to ensure adequate production of Specialists for the country. Different Specialist functions exist in the 5 hospitals scattered in and around Freetown. The conglomerate of hospitals (Connaught, Lakka, Princess Christian Maternity Hospital, Ola During and Kissy Mental hospital) will form the University-Hospital complex with COMAHS. The regional hospitals (Makeni, Kenema and Bo) will be affiliate hospitals to ensure sharing of training resources and knowledge exchange. In order to establish the programme, an act of parliament establishing a university-hospital teaching complex is required. MoHS worked with partners to develop an act which will be taken to Parliament in the coming few months. Once the act is approved in Parliament, MoHS will establish the programme and enrol the first group of medical officers for post-graduate training. This initiative will ensure that Sierra Leoneans have access to the comprehensive spectrum of health care from the primary level to the tertiary care. KEY PRIORITY THREE: ESSENTIAL HEALTH SERVICES“the country's failure to clearly separate its EVD treatment units from regular health facilities had destroyed confidence in hospitals and clinics. We are struggling to regain confidence in our health facilities because of this mistake. About 50 per cent of the deaths in the country are not Ebola but, because people fear to come to some of our healthcare facilities, they die needlessly due to other treatable diseases” Ms. Madina Rahman, Deputy Minister of Health & Sanitation II 32766001631315Key StrategiesRestore Malaria, EPI, child and maternal health services programmes to pre-outbreak levels in transition phaseStrengthen child health through IMNCI, RED approachStrengthen maternal and adolescent health with special emphasis on neonatal health and teenage pregnancy preventionStrengthen communicable and non-communicable diseases control with strong emphasis on surveillance and response at all levelsEstablish demand-driven essential medicines list supply systemStrengthen laboratory diagnostic and imaging services capacities, improve safe transfusion and emergency services, Improve support and enabling environment for BPEHS delivery00Key StrategiesRestore Malaria, EPI, child and maternal health services programmes to pre-outbreak levels in transition phaseStrengthen child health through IMNCI, RED approachStrengthen maternal and adolescent health with special emphasis on neonatal health and teenage pregnancy preventionStrengthen communicable and non-communicable diseases control with strong emphasis on surveillance and response at all levelsEstablish demand-driven essential medicines list supply systemStrengthen laboratory diagnostic and imaging services capacities, improve safe transfusion and emergency services, Improve support and enabling environment for BPEHS deliveryThe BPEHS for Sierra Leone (BPEHS, 2010) provides the norms and standards for key areas of service delivery – defining what interventions should be administered at each level of care. Despite substantial recent progress towards the MDG targets and improvements in coverage with essential interventions prior to the Ebola, a number of challenges have constrained the implementation of the BPHES – resulting in continuing high levels of preventable maternal and child deaths. The Ebola epidemic served to further erode community trust in the health system, adversely affecting service utilization. Restoring confidence in the health system and ensuring essential services are available and accessible at all levels of care are the utmost priorities in the recovery period. 7.1 Getting to Zero and Transition Phase7.1.1 Restore the critical elements of the BPEHSRestoring hey health programmes is a key priority for the health sector and is part of the key interventions that will be monitored by the Office of the President in the next 6-9 months. Facility improvement during the transition phase will be a key component of restoring key health care programmes. It will also be important to restore confidence in primary health facilities to the provision of non-Ebola health services. Drawing upon networks of social mobilization organizations and actors deployed during the Ebola crisis, a community sensitization campaign will be launched with health promotion messages on child health campaigns, the safety of health facilities, the Free Health Care Initiative, and encouraging communities to use these systems to address health issues, with an emphasis on accessing critical MNCH interventions. To address the lack of confidence many communities experienced in the wake of Ebola, a facility refurbishment exercise will be undertaken. This will include community sensitization efforts – with messaging around the safety of facilities and resumption of routine service delivery; efforts to improve the cleanliness of facilities; and measures to provide basic equipment to facilities to address shortages and support the resumption of care services. In restoring the essential health services, the following will be the focus for the 6-9 months period as we work toward getting to zero:Conduct intensive targeted immunization campaigns; Provide free health care to adults with malaria;Recapture defaulted TB and HIV patients;Restore critical RNMCH services safely;Audit and reform HR and supply programs; and Provided free health service for 3500 Ebola survivorsConduct intensive targeted immunization campaigns: National house-to-house campaigns are conducted each May and November to enhance coverage with critical child health interventions including vaccines. During 2014, these activities were suspended due to the Ebola crisis. Measles has already been reported in early 2015 across several districts. Urgent campaign-style delivery of a range of child interventions including measles and polio immunization, vitamin A, deworming, and the screening and management of acute malnutrition is therefore a key priority. Planning is underway for a national campaign in April-May2015. Periodic Intensified Routine Immunization (PIRIs) will also be conducted.Provide free health care to adults and reinforce malaria control efforts: Malaria remains the number one cause of morbidity and mortality in Sierra Leone. In June 2014 at the start of the Ebola epidemic, the second insecticide treated bednet distribution was conducted, reaching 3.5million people with 96% household coverage. Similarly, a mass antimalarial drug administration in December 2014 and January 2015 reached 2.5 million people. Moving forward, the health sector will support effective decentralised malaria testing and treatment efforts as we approach the rainy season in mid-2015. Refresher trainings are required on malaria testing and case management for CHWs, PHUs and hospital staff, alongside training for hospital laboratory staff on malaria diagnosis. The procurement of reagents, supplies and rapid diagnostic kits to support malaria diagnosis remains essential. Provision of free health care for adults with malaria is one key intervention that will be prioritized. Recapture defaulted TB and HIV patients: As the health sector struggled with loss of trust in health care facilities, thousands of TB and HIV patients were lost to follow up, with the HIV/AIDS programme estimating up to 4,000 patients on treatment lost to follow up. A critical part of the recovery plan is to operationalize the health sector’s intention to recapture all TB and HIV patients on long term treatment and ensure that they are retained in care.Strengthen child health through Integrated Management of Newborn and Childhood Illness (IMNCI) By early 2014, 4 districts had attained over 60% WHO required IMNCI staff training coverage. Considering the reduced utilisation of health services by under-five children during the outbreak, the priority will be a systematic roll-out of nation-wide IMNCI training with a focus on CHCs. Supportive supervision to ensure high quality of IMNCI service provision will also be emphasized. Strengthen maternal and adolescent health with special emphasis on neonatal health and teenage pregnancy prevention: Other consequences of the EVD outbreak on access to health services include a much lower proportion of women reporting pregnancy-related care and as much as 90% drop in family planning visits. The health sector will focus the first 6-9 months on restoring access to pregnancy-related care among women; addressing the impact of EVD on teenage pregnancy and implement teenage pregnancy prevention programmes. A policy on adolescent health will be developed before the end of December 2015. The currently ongoing programmes to upgrade into BenMOC and CenMOC several CHCs, will support this effort. 7.1.2 Strengthen communicable and non-communicable diseases control Establish isolation units: In response to the Ebola crisis, facilities were refurbished for EVD suspects awaiting diagnosis with staff retrained in IPC standards. In early 2015, most of these ‘Holding Centres’ were closed for Ebola care and are being re-purposed as isolation units. These will support the isolation of suspects for endemic and locally epidemic diseases such as tuberculosis, measles, Lassa fever and cholera. Select facilities in high volume district hospitals should be converted to TB wards and support specialized pediatric TB services. Improved surveillance: The EVD epidemic exposed gaps in the country’s surveillance system. There is strong interest from international development partners in supporting interventions linked to this component and discussions have focused on how best to build on the systems and mechanisms developed during the EVD epidemic.7.1.3 Establish demand-driven essential medicines list supply systemUpdating policy, standards and guidelines: To align with the WHO Essential Medicines List (EML) and to place emphasis on the life-saving commodities, the Sierra Leone EML was revised in 2014. The recently concluded revision of the BPEHS takes this into account and provides guidelines for enabling essential medicines, particularly those provided through the Free Health Care Initiative, availability at the lowest appropriate level of care. Drugs and supplies availability: The Free Health Care Initiative will be re-enforced with parallel efforts to strengthen drug warehousing, distribution and effective supply chain management so PHUs have medicines and related services available as a matter of urgency. The drugs supply chain in Sierra Leone currently operates on a push system, which leads to frequent stock-outs of essential medicines and over-stock and expiring of less frequently used medications. A priority in the recovery phase will be to revise the supply chain system and move towards a more pull-oriented system, wherein PHUs receive drugs and supplies based on their reporting of their utilization and needs.Strengthening cold chain infrastructure: Few health facilities in Sierra Leone have working refrigerators, solar systems or generators to maintain vaccine cold chains. An inventory of cold chain facility infrastructure is planned for March 2015. Repair or replacement of faulty infrastructure, re-positioning of existing infrastructure from the Ebola response (i.e., generators) and the purchase of new infrastructure as required to address cold chain gaps will be prioritized. Strengthen laboratory diagnostic and imaging services capacities Prior to Ebola, laboratory systems were characterized by many of the same challenges faced by other sectors with shortages of infrastructure and supplies, adequately trained staff, poor storage and transport systems, and insufficient monitoring. To address these gaps, strategies to improve laboratory and blood transfusion systems have been outlined in the National Health Laboratory Strategic Plan (2011-2015) and the Blood Safety Strategic Plan (2011-2016) respectively. International support for the Ebola response resulted in an unprecedented influx of laboratory technicians, equipment and supplies – including a hub-in-spoke specimen collection system using motorbikes with mounted cooler-boxes that has been very effective. Many of these items will remain in-country and can be re-purposed – creating major opportunities to up-scale diagnostic capacity for a range of conditions in Sierra Leone, including for blood transfusion services. A number of immediate and medium-term strategies have been identified to further these efforts. Post-Ebola laboratory capacity assessment and medium-term-planning exercise: A full inventory of equipment is underway by the Laboratory Technical Working Group of the MoHS with global partners. An assessment will be undertaken to better understand which equipment will remain in Sierra Leone, what additional staff training will be required, how to optimize the positioning of these facilities in relation to four regional centers of excellence, the suite of diagnostic testing that can be offered in relation to the local disease burden, and a medium-term budget for the training, supplying, testing, storage, transport and maintenance of these systems.7.2 Early Recovery PeriodIn preparation of this Health Sector Recovery Plan, the BPEHS was reviewed and updated. The thematic areas of the BPEHS most relevant to the early recovery period are profiled below, highlighting strategies to address challenges identified and accelerate implementation. Critical first steps will include addressing immediate post-Ebola vulnerabilities – with a focus on ‘catch-up campaigns’ to rapidly deliver essential interventions including vaccinations, malaria control, screening and management of acute malnutrition, and diarrhoea management. Efforts to restore uptake of maternal health services including ANC and skilled delivery, and to enhance basic emergency obstetric care, will be critical for reducing maternal and newborn deaths. 7.2.1 Environmental healthWater and sanitation (WASH) is a cross-cutting environmental health issue that has profound effects on Ebola prevention and care services, as well as for other epidemics such as cholera. In the recovery period, establishing and re-establishing basic WASH standards in health facilities is an urgent priority for patient and health worker safety, IPC, as well as basic services that are WASH-reliant such as obstetric care.District environmental health plans will be developed for health care facilities and communities - drawing together the MoHS, Ministry of Water Affairs and relevant partners. Plans will include site assessments; rehabilitation of any WASH facility (hospitals and clinics) directly or indirectly used for Ebola; corresponding improvements and rehabilitation of WASH services at central and regional hospitals and health centers; establishing needed infrastructure that was lacking prior to the Ebola crisis and hindered response efforts, such as provision of safe water and excreta disposal facilities (latrines); testing laboratories and sludge treatment systems – such as construction of Freetown and regional water and sludge treatments works. Plans will also include establishment of solid waste management facilities in populated areas, including positioning of incinerators and equipment for handling hazardous wastes in health facilities. Recruitment of additional professional staff into the health (environmental health and sanitation directorate) and WASH sectors will be undertaken as appropriate.7.2.2 Ambulance and fleet management services Since the beginning of the response, there has been a major influx of vehicles (including ambulances) to Sierra Leone supported the Ebola response. A full inventory of these assets, in collaboration with partners, was underway at the time of concluding the recovery plan. These vehicles (motorcycles, trucks, ambulances) will be re-positioned to support a range of post-Ebola activities including community-based disease surveillance; district level support and supervision of health facilities; support to supply chains to enhance the timely delivery of essential medicines; and ambulance services for community-based emergencies and referrals. To ensure these vehicles are managed efficiently and to maximize accountability, options regarding the potential public private mix approach to management of these assets are being explored. 7.2.3 Expanding national 117 dial-in/alert center for broader health informationDrawing from the influx of resources to support the Ebola response, in addition to the national ambulance and fleet management, referral systems will be further revitalized through revival of the 112 call centre – a regulated call centre meant for emergency services. A dedicated emergency number (it could remain the currently existing 112 line) will be established and maintained to support the national ambulance service. Such a number would need to operate without a SIM card and not affected by network control on ability to make calls, therefore providing more reliability to the emergency service. As an immediate step in the post-Ebola recovery period, the 117 ‘alert’ line that was widely promoted during Ebola response will be expanded to support a wider range of support services related to health. Guidelines for the effective utilization of these services will be established by the MoHS.2949575-195580112 or an alternative new numberEmergency health / ambulance service – system for receiving health alerts and feeding them into the health system, with ambulance dispatchGeneral emergency service system – A 24/7 central line for all emergency services (similar to the 911 service in the United States of America)00112 or an alternative new numberEmergency health / ambulance service – system for receiving health alerts and feeding them into the health system, with ambulance dispatchGeneral emergency service system – A 24/7 central line for all emergency services (similar to the 911 service in the United States of America)-106045-204470117 (expanded functions)Disease outbreak early warning system – A call centre that would serve as an entry point for alerts from a Community Event Based Surveillance (CEBS) systemTelephone-based psychosocial services – Staffed with trained psychosocial therapists to counsel those affected by EbolaGeneral health information00117 (expanded functions)Disease outbreak early warning system – A call centre that would serve as an entry point for alerts from a Community Event Based Surveillance (CEBS) systemTelephone-based psychosocial services – Staffed with trained psychosocial therapists to counsel those affected by EbolaGeneral health information7.2.4 Rehabilitation and facility equippingSierra Leone has nearly 1,200 health facilities with approximately 80% of the population residing within 5 km of a health facility. Many facilities lack basic amenities and equipment necessary to support the effective delivery of essential services. In many instances, an absence of staff accommodation creates challenges to attract qualified staff and remain open 24/7 as appropriate. 7.3 Recovery PhaseThe basic package of essential health services is specific on services that the population can expect at the various levels as well a the human resource, infrastructure and equipment needs etc. Full implementation of the Basic Package requires that sufficient resources are made available, in terms of financial, human resources, material and supplies. With regards to implementation of programme-specific interventions, the health sector will maintain and sustain ongoing projects during the recovery phase and beyond. KEY PRIORITY FOUR: COMMUNITY OWNERSHIPQUOTE29959301314450Key StrategiesEnsure community groups of key stakeholders (dialogue structures including women and youth) and networks are established and systematically engaged in BPEHS implementationEnsure key community groups and networks are engaged in community surveillance, case investigation and other key operational eventsEnsure key policies, strategies and guidelines on community engagement are developed to support the implementation of the BPEHS00Key StrategiesEnsure community groups of key stakeholders (dialogue structures including women and youth) and networks are established and systematically engaged in BPEHS implementationEnsure key community groups and networks are engaged in community surveillance, case investigation and other key operational eventsEnsure key policies, strategies and guidelines on community engagement are developed to support the implementation of the BPEHSMeasures to enhance community ownership and involvement in the post-Ebola recovery period are essential for rebuilding trust in the health sector and recapturing progress towards the missed health and nutrition MDG targets. Strategies to enhance community ownership will focus on revisiting policies and guidelines to foster community participation in the health sector; re-invigorating systems to foster community dialogue; formalizing community based approaches to health service delivery; and improving linkages between communities and facilities, including empowering communities to hold the health system accountable for accessible and high quality service delivery. Robust community-owned systems are critical for mounting an effective Ebola response, as well as for supporting wider health gains. For example, promoting behaviour change around early isolation and safe burials required strong links between the health system and communities. The passage and enforcement of local by-laws and decrees by traditional leaders provided visible political commitment to address the epidemic. Working through community networks such as religious groups (churches and mosques), women’s groups and youth groups enhanced effective messaging and mobilization – including safety of routine health services and when to use them. Finally, neighbourhood watch programs and community surveillance efforts made a major contribution towards active surveillance and early case detection and referral. Several factors limited the effectiveness of the community response early on in the epidemic. The absence of budgetary allocations for community health workers alongside ‘no-touch’ considerations placed a hold on household-level engagement. Weak facility management committees were poorly equipped and ill-prepared for addressing the challenges of infection prevention and control in health facilities, high numbers of health worker infections, and the resulting loss in community confidence in the system. This was compounded by insufficient linkages between communities and the health system; limited opportunities for dialogue between district health management teams (DHMTs) and local communities; and poor networks for behaviour change communication, advocacy and social mobilization. 8.1 Getting to Zero and Transition PhaseTaking into consideration the lessons learned and challenges outlined above, the following strategies have been identified to advance key areas relevant to building community ownership of health systems and services.8.1.1 Establish community groups of key stakeholders and networks Community groups of key stakeholders and networks are broad and include dialogue structures such as key affected populations, women and youth. Establishing DHMT-community dialogue on health issues is an urgent priority. Concerted effort will be made to strengthen health system-community linkages and rebuild trust in the public health system. A community engagement function will be introduced within DHMT, as part of the National Health Promotion Strategy outlined above. The DHMT will be responsible for initiating quarterly community meetings with paramount chiefs, religious leaders and community stakeholders. Communication will be two-way – the focus will not be only on communicating on public health emergencies and on prevailing health issues, but will also provide an opportunity for community members to identify gaps and propose solutions. 8.1.2 Engage community groups and networks in community surveillance Community based surveillance is a critical component of the Integrated Disease Surveillance and Response (IDSR) approach promoted by WHO in the Africa Region and endorsed by Sierra Leone in 2003. However, to-date community based surveillance of notifiable diseases has been limited, enabling the rapid spread of EVD in 2014 in Sierra Leone without a commensurate early response. Over the course of the epidemic response, these systems have been strengthened substantially. The MOHS has recently endorsed a Community Event-based Surveillance (CEBS) that builds on existing CHW networks to report on suspicious Ebola events in line with established triggers. Initial pilot work in generating reports using mobile Health applications is showing great promise. The ‘mHero platform’ (Mobile Health Worker Electronic Response and Outreach) allows community surveillance officers to file reports using mobile phones, which integrate with DHIS2, the cloud-based health information management system (HMIS) adopted by Sierra Leone. Reports requiring follow up will be communicated to the ‘Alert’ hotline at the District Ebola Response Centre (DERC) and will be investigated by surveillance teams. The CEBS system is currently rolling out nationwide. While developed for Ebola, these systems are being adapted to support other epidemic and endemic diseases – which is a major strategic priority moving forward. The health sector will ensure that community groups of stakeholders are also engaged in case investigation and other key operational events.8.1.3 Develop key policies, strategies and guidelines on community engagement To support the implementation of the Basic Package of Essential Health Services, it is essential to strengthen community systems and structures. The health sector will develop relevant policies, strategies and guidelines that will provide a framework for community engagement. In addition, a National Health Promotion Strategy outlining the role of community participation within the health sector will be developed and operationalized. The strategy will review the importance of the community contribution to health alongside the roles and responsibilities of relevant stakeholders at the national, district and facility levels. The focus will be on strengthening community involvement in health promotion and surveillance efforts. This strategy will include revitalising community structures such as Christian Action Group (CHRISTAG) and Islamic Action Group (ISLAG), community health clubs, school health clubs, CAGs, FMCs, and mother support groups. It will also include reinforcing vital community surveillance networks that have emerged through the Ebola response. A monitoring and evaluation framework aimed at better tracking community level interventions, including behaviour change communication and social mobilization activities will also be developed and implemented. Its implementation will occur in tandem with strengthening MOHS capacity to monitor and supervise community level interventions.8.2 Recovery PhaseThe Community Ownership component of the Health Sector Recovery Plan also aims to address the barriers identified and build on the momentum and success of the Ebola response to re-invigorate and sustain effective community engagement in the health and nutrition sectors. Specific focus areas include revitalizing Facility Management Committees and District Health Coordination Committees. Community involvement in surveillance activities will be supported by a strong mobile health (m-health) strategy. Of equal importance is the strengthening of community structures that can hold the Government, development partners and NGOs accountable for the provision of quality health care. Finally, lessons learned from Ebola social mobilization efforts will inform demand generation programmes to support behaviour change and improve health seeking behaviour for other key health interventions. 8.2 1 Engage community groups of key stakeholders in BPEHS implementationStrengthen decentralized community health management structures including Facility Management Committees: Substantial investments have been made to support community involvement in the health sector including peer support networks, community nutrition programs, DOTS supporters for tuberculosis, awareness raising around challenging issues such as teen pregnancy, female genital mutilation and so forth. To complement these efforts, steps towards improving community-health system linkages will be undertaken. Health Facility Management Committees have a long history in Sierra Leone, with varying degrees of effectiveness and functionality. These Committees will be rejuvenated through the introduction and implementation of operational guidelines, providing training and refreshers as needed, responding for identified areas of perceived need, ensuring they are resourced and equipped as needed, and that systems for monitoring their engagement are established. These Committees are the primary mechanism through which community leaders and members will be informed, educated and empowered to understand their role in improving health services and the importance of utilizing the systems in place. Furthermore, Community Advocacy Groups (CAGs) will be established and functional in all communities throughout the country. In order to further facilitate strong linkages with a central level, a National Community Health Programme within Directorate of Primary Health Care will be established. 8.2.2 Ensure key community stakeholders are engaged in community-based surveillanceStrengthen community-based health service delivery: As outlined in the chapter above on Health Workforce and Productivity, the Community Health Workers (CHW) program will be formalized and strengthened. This will include a clear, harmonized set of practice guidelines as well as more effective implementation of monitoring systems introduced under the CHW policy framework in 2012. In the context of the National Health Promotion Strategy, community leaders will also be oriented to the role of CHWs and be engaged in supporting their work at the community level. CHWs will be supported to be a more effective link between health facilities and households, with an emphasis on their role in health promotion and community surveillance in addition to their existing roles in direct basic service delivery. Sensitization of communities: In addition to training Community Advocacy Groups (CAGs), Facility Management Committees (FMCs), traditional healers and traditional birth attendants in specialized disease surveillance for epidemic-prone communicable diseases, sensitization campaigns to raise awareness of communities on the importance of reporting epidemic-prone diseases and promoting the utilization of reporting line will be rolled out. 8.2.3 Develop key policies, strategies and guidelines on community engagement Establish a national mechanism for stewardship, coordination and management of community-level interventions: To enhance the profile and effectiveness of community engagement in the health sector, leadership and coordination mechanism will be established at central and district levels. The aim will be to improve equity, reduce duplication, establish common reporting systems and maximize shared learning from the collective national response.As part of this initiative, a Community Health Information System will be developed to enable community structures to coordinate and share information and data. The system will also enable effective communication on health alerts, such as for Ebola outbreaks or other diseases and patterns that warrant immediate attention. This system will be coupled with a community health expenditure tracking system so as to link investments with community level outputs. Data collected and managed by these systems will be published and shared based on community health information publishing and reporting mechanisms which will also be developed.KEY PRIORITY FIVE: INFORMATION & SURVEILLANCEQUOTE31242001104900Key StrategiesImplement integrated disease surveillance and response systems (including Ebola)Establish a functional national laboratory network with increased capacity of quality assessment, information system, and supervision Strengthen health information system00Key StrategiesImplement integrated disease surveillance and response systems (including Ebola)Establish a functional national laboratory network with increased capacity of quality assessment, information system, and supervision Strengthen health information systemThe Ebola outbreak highlighted Sierra Leone’s potential to use data for decision making and to better target services and resources where they are most needed. Monitoring systems based on case-finding, contact tracing and Community Event-Based Surveillance (CEBS) were established to support the Ebola response. These systems were linked with laboratory and admissions data to draw a fuller picture of the outbreak and to focus efforts. Harnessing lessons learnt from this experience and applying them to routine information and surveillance systems is a critical priority for the post-Ebola recovery period. Prior to the Ebola epidemic, these systems were not functioning optimally. The capacity to collect, analyse and use disease surveillance and administrative data (finance, human resources and logistics management) needs to be improved. Reliable data and information need to be shared promptly and regularly for timely and effective Integrated Disease Surveillance and Response system. Communication amongst frontline health workers in the districts, epidemiologists and disease prevention and control authorities as well as disaster risk management officials has to be conducted effectively and efficiently. The adoption of District Health Information System 2 (DHIS) by the MoHS is an important achievement. Deployment is on-going and currently limited to routing service data from primary and secondary facilities. Initial progress was made in the use of DHIS data for decision making, but the process of sector review is yet to be institutionalized. Other challenges include timeliness, completeness and quality of data; a scarcity of systems and paucity of capacity at the PHU level, coupled with fragmented reporting tools (HIV, TB, Malaria), limited private sector engagement and weak systems for collecting data on vital statistics. National Technical Guidelines for IDSR were formulated since 2008, but are yet to be implemented.Priority areas have been identified to strengthen information and surveillance systems in the post-Ebola phase. These include systemizing and institutionalizing data-driven decision making at all levels of the health system by creating an Information and Surveillance Unit to coordinate monitoring, evaluation and surveillance budgets and activities across programmes and directorates. The operationalization of such a unit will also serve to eliminate siloed data systems and harmonize data collection tools and data warehousing. The full implementation of a Health Management Information System by expanding the DHIS2 system will also be a key priority. Similarly, expanding the reach of the Logistics Management Information System to the district and facility level will facilitate more effective procurement and supply chain management. From a surveillance perspective, the MOHS will develop an early warning system that enables the health sector to more quickly recognize and respond to hazards. This will be complemented by developing the core capacities for disaster risk management, including pre-positioned infrastructure, surveillance and laboratory capacity to rapidly detect and respond to emerging outbreaks, including EVD. 9.1 Getting to Zero and Transition PhaseThe EVD outbreak highlighted critical gaps and weaknesses in surveillance systems. The health sector will implement integrated disease surveillance and response systems that will ensure the country readiness to address future threats, including Ebola. 9.1.1 Integrated Disease Surveillance and Response (IDSR)The National Technical Guidelines for IDSR were formulated since 2008, but are yet to be implemented. An IDSR rapid assessment conducted in January 2015 revealed major shortcomings that included among others lack of reporting tools, difficulties with transmitting data, limited access to laboratory confirmation of priority diseases all resulting in low timeliness and completeness of reporting. Drawing upon the experience gained through the Ebola response, robust real-time surveillance will be institutionalized and further strengthened under the leadership of the District Health Management Team (DHMT) and coordination of the Directorate of Disease Prevention and Control (DPC). As outlined in the Community Ownership section, the community based surveillance platform implemented as part of the Ebola response will be expanded to include non-Ebola related endemic and epidemic disease – including cholera, Lassa, measles and malaria. A Rapid Response Protocol developed for Ebola will also be institutionalized and expanded to support a wider range of use-case scenarios and there will be a revitalization of the Rapid Response Teams (RRTs). Surveillance teams in the districts, building upon and integrated within established Disaster Management Committees, will be strengthened based on revised IDSR. These efforts will build on work that has already been initiated, including the adaptation of the IDSR 2010 Technical Guidelines, the adaptation of the training modules and the validation of the revised technical guidelines. Specifically in 2015, the emphasis will be on provision of tools and training of health workers at the district level and supervision and monitoring of the health workers trained on IDSR. 9.1.2 International Health Regulations (IHR) IHR will be an area of priority focus in 2015. There will be a an assessment of the core capacities to identify gaps, interventions and associated costs. This assessment will inform work that needs to be completed by end 2016. Advocacy around IHR and its implementation will also be encouraged through updating existing legislation to facilitate exercising IHR rights and by implementing policies and strategies already in place. The Public Health Act of 1960 will also be reviewed and updated to reflect learnings from the Ebola outbreak and surveillance imperatives.9.1.3 Establish surveillance related coordination and communicationCommunication and information systems established to manage the Ebola outbreak will be reviewed and retained based on effectiveness. While disease specific guidelines, a taskforce to handle outbreaks, and a unit for the coordination of risk communication among stakeholders during an emergency are present, not all private and NGO operated health facilities currently report into the national and district surveillance systems. Thus, mechanisms to ensure all these facilities harmonize and coordinate surveillance reporting will be implemented.9.2 Early Recovery Phase9.2.1 Build surveillance capacity Surveillance capacity at the national and district levels will be enhanced by relocating existing Ebola assets from the National Ebola Response Centre (NERC) and District Ebola Response Centre (DERCs) to the MoHS and DHMTs respectively. Gaps identified through an assessment of human resources (nutrition and disease surveillance officers, laboratory officers, etc.), processes (guidelines, procedures, tools, specimen collection and transportation, etc.) and systems (laboratories, VHF communication in health facilities) will be addressed. Disease and nutrition surveillance officers will mobilize existing Ebola-related human resources to improve national staff capacity. In addition, opportunities to participate in continuing education in partner countries will be explored.9.2.2 Establish a functional national laboratory network Having a national laboratory network that functions optimally and has appropriate and adequate capacity to conduct quality assessment, information system, and supervision is critical to health sector recovery. This is a core capacity under International Health Regulations (IHR). Establishment of the national laboratory network will be in line with the recommendation from the IHR assessment.9.2.3 Strengthen Health management information systems (HMIS)An evaluation of the existing Health Management Information System (HMIS) will be conducted to assess the number and capacity of HMIS officers and data entry clerks; the suitability of existing infrastructure and materials at health facilities and DHMT offices including electrification and IT equipment, and; the adequacy of tools and mechanisms to support information dissemination and utilization. Furthermore, the established iHRIS, already in use in Sierra Leone will be integrated within DHIS 2 to provide an overview of health worker numbers, constituency, and deployment along with health service statistics. iHRIS data on health workers will also be reviewed to ensure deployment aligns with central guidelines and health needs. Readiness for the introduction of an electronic medical records (EMR) system will also be examined. The implementation and overall status of DHIS2 will be reviewed and plans to more fully deploy and integrate it with other HMIS systems will be implemented.This assessment will inform the recruitment and placement of data entry clerks and IT officers to support the HMIS and iHRIS systems. HMIS will be expanded to incorporate vital statistics data. Connectivity at health facilities will also be improved through appropriate electrification in addition to installing satellite internet at DHMT offices. Information and data gaps in HMIS, iHRIS and DHIS identified through the assessment will be addressed. Depending on the findings of the EMR readiness assessment, plans to develop and roll-out EMR will be developed.9.3 Recovery Phase 9.3.1 Further strengthening of IDSRInstitutionalizing IDSR: The health sector will institute regular monitoring and supervision to ensure institutionalization of IDSR. The HMIS (DHIS platform) could function as a backbone for surveillance related reporting, as it already has information on the facilities and mobile reporting functionality – this aspect will be strengthened. An integrated information system will be critical and will be further developed.International Health Regulations (IHR): Based on the findings of the 2015 IHR assessment, there will be the implementation of all core capacities to ensure that that the country is compliant with IHR. Establish an M&E coordination unit: The existing M&E coordination unit at district and central levels including regional referral hubs that functions across programmes and directorates and coordinates M&E related activities, including the revision and harmonization of tools, integration of data management systems, data warehousing and oversees data quality assurance processes will be strengthened. The M&E coordination units will coordinate and provide oversight for M&E at the district level. Terms of reference will be developed for the M&E coordination all levels units to guide its work and relationships.Establish mechanisms for the use of data for decision making: Additional national and district level M&E support officers will be hired and a monitoring framework developed to assess progress against the revised BPEHS and the new sets of post-2015 targets moving forward. Information collected by health facilities, CHWs and CEBS monitors, as well as from the integrated Human Resource Information System (iHRIS), will be compiled and synthesized to track progress across the system. Training on the use of data for decision making will be cascaded from the national level down to districts and facilities, with mechanisms established to ensure feedback mechanisms with actionable data and information are available in a timely manner to inform and improve program management decisions in the health sector. Regular national health sector reviews will also be conducted.9.3.2 Increase capacity of quality assessment, information system, and supervision As outlined in Essential Health Services section above, leveraging Ebola-related resources to enhance laboratory capacity will be a fundamental pillar of the recovery plan. This includes the establishment of public health reference laboratories in regional hubs as outlined in the Health Workforce and Essential Health Services sections. It also includes ensuring secondary hospitals and peripheral health units have adequate training, equipment and materials required for diagnostics to support routine needs as well as surveillance activities for epidemic disease such as Ebola. Finally, an information system will be strengthened to support the rapid and accurate reporting of results into Regional and National data bases and implement the recommendations from the IHR assessment in 2015. 9.3.3 Strengthen Health management information systems (HMIS)Health Information System (HIS): A HIS policy and strategic plan will be and the capacity to implement the strategic will be developed. The existing package of indicators in the Results and Accountability will be updated to better reflect the priorities in the Health Sector Recovery Plan. It will draw on the work done by all the districts and will identify targets and regular monitoring and review mechanisms.District Health Information System 2 (DHIS 2): Ensuring timeliness, completeness and reliability of data will be main areas of focus to strengthen the DHIS 2. Linkages between the different levels of data collection (community, facility, district and national) will also be improved along with the establishment of an integrated data collection system. The option of linking DHIS 2 with mobile devices in all health facilities that can be used to report notifiable diseases and provide feedback to all levels will also be explored. This could be potentially more efficient and sustainable than developing a separate system for diseases surveillance. It should be accompanied by review of the roles and responsibilities within the different departments within the ministry. Supportive supervision will be strengthened at all levels. In addition, a review of the roles and responsibilities within the different departments within the MoHS will be conducted.Civil registration and vital statistics (CRVS): According to the 2013 DHS birth registration coverage was 77% among children under five years. In 2014, 199,259 births were registered, which corresponds with almost 80% coverage. However, death registration is low, with only 12,827 deaths recorded in 2014 (about 20% of expected deaths). A Medical Certificate of Cause of Death is used at the hospital level, but there is no ICD training and no capacity to develop national cause of death statistics based on this. Data collection and management is paper-based at all levels. A rapid assessment of the CRVS was recently done, but no comprehensive assessment and strategic plan that involves all relevant sectors have been developed.Therefore, a national strategic plan for (CRVS) strengthening will be developed and which will take into consideration human resources, training, infrastructure, computerised database, logistics, transport, community sensitisation, and financing needs. Establishment of a high-level coordination mechanism for CRVS system strengthening, under president’s office, involving all relevant sectors including a major role for MOHS will be explored. Closely linked to this effort will be the development, training and use of the ICD-10 manual along with sensitisation campaigns to encourage reporting of community deaths.ENABLING ENVIRONMENTQUOTE34931351103630Key StrategiesImprove leadership and governance at the central levelStrengthen the capacity of districts to implement the health sector recovery planImprove accountability for health sector recovery implementationWork with relevant sectors to further the Sierra Leone Health InsuranceWork with other sectors (and MDAs) to develop and implement cross—sectoral initiatives 00Key StrategiesImprove leadership and governance at the central levelStrengthen the capacity of districts to implement the health sector recovery planImprove accountability for health sector recovery implementationWork with relevant sectors to further the Sierra Leone Health InsuranceWork with other sectors (and MDAs) to develop and implement cross—sectoral initiatives The year 2020 is a symbolic to the health sector. The full implementation of the Basic Package of Essential Health Services is pegged against the year 2020. The health sector recovery plan is also pegged against the same year. The health sector will use the earlier phases of the recovery plan 2015 – 2020 to establish a solid platform for implementing interventions that will contribute towards the longer term and sustainable impacts for the sector. -2242873529414Figure 5: The road to recovery showing the phase focusing on achieving the health sector’s vision 202000Figure 5: The road to recovery showing the phase focusing on achieving the health sector’s vision 2020-22479063500Although interventions implemented during earlier phases will provide a platform for the four years of solid long term solutions, the health sector will focus on these types of interventions on a full-scale from second quarter of 2017. Of significant importance is that this phase will be implemented under the Agenda for Prosperity, the development framework for Sierra Leone under the current Government. 10.1 Continuous improvement to leadership and governance at all levelsStrong Governance, Leadership and management are core components for strong health systems. In order to deliver the health sector recovery plan over the next several years, the health sector will need to have sufficient leadership and management capacity to steer the plan toward achieving the intended goals and objectives. The health sector will develop a comprehensive leadership, governance and management capacity building strategy and plan. The strategy and plan will focus on improving central level leadership; improve functioning of hospitals; ensure appointment of competent, skilled managers; provide accountability framework, and ensure capacity building of senior officials in the Ministry on leadership, management and governance. The intention is for the Ministry of Health and Sanitation to become a beacon of good practice in leadership and management. 10.2 Strengthen capacity of districts to implement the recovery planThe health sector is aware that to implement the health sector recovery plan successfully, district and local level implementation is very crucial. Capacity across the 13 districts varies. Building on the functionality of the District Ebola Response Centres (DERCs) during the fight against ebola, the health sector will transfer capacity and skills from the DERCs as the country right-seizes the Ebola response. The leadership, governance and management strategy and plan will include the district health management teams and facilities as levels of interventions. Another area that requires significant strengthening is fiduciary controls at the district, hospital and local council levels. The Auditor General’s Audit Report on Ebola Funds for the period May to October 2014 showed that lack of compliance to financial management policies and regulations. The Ministry of Health and Sanitation intends to ensure that each transaction is backed with solid supporting documentation as per regulatory requirements. 10.3 Improve accountability for health sector recovery implementationA range of established and new partners have provided invaluable cross-sectoral support to Sierra Leone in the Ebola response – contributing resources, infrastructure and skills at the national and district levels. Through the National Compact, efforts are underway to ensure that these partnerships contribute towards the post-Ebola recovery and health systems strengthening activities outlined in this Plan. Specific areas of focus are outlined under relevant sections. All implementers will be required to provide a comprehensive package of services as determined for the health sector. To operationalize this, the Ministry of Health and Sanitation will develop Service Level Agreements (SLAs) which will be signed by the Ministry at the central and DHMT level as well as with the implementing partner. The SLA will be accompanied by an accountability framework. In case an implementing partner is unable to deliver the comprehensive package, they will be requested to form consortiums that include other partners with comparative advantage in different aspects of the comprehensive package to implement the package together. The idea is that service provision should be comprehensive and not piece meal.10.4 Efficient and sustainable financing mechanismIn order to ensure successful implementation of the health sector recovery plan, the Ministry of Health and Sanitation will work with the Ministry of Finance and Economic Development (MOFED) and donor partners to ensure that the plan and the associated basic package for essential health services are fully funded. The Ministry of Health and Sanitation will work with partners to ensure more predictability and sustainability of funds flowing to the health sector. The health sector is also keen to ensure efficient use of resources that flow into the health sector. To complement the accountability mechanism described above, the health sector will place increased emphasis on value for money. This will extend the focus of the Ministry of Health and Sanitation from ensuring availability of supporting documents for transactions to enhancing the quality of such documents. Universal health coverage remains a key ideal of the Government of Sierra Leone as articulated in the Agenda for Prosperity (2013 – 2018). Establishing and implementing a National Health Insurance, in particular a community-based health insurance scheme using a tiered approach has been shown to be the best option for ensuring universal health coverage. In Rwanda, using this approach increased coverage to 90% by 2010. Sierra Leone will learn lessons from the Rwanda experience and work with partners and relevant Government MDAs to move forward the Sierra Leone Social Health Insurance (SLeSHI). 10.5 Develop and implement cross-sectoral initiativesThe health sector recognizes that there are several interventions that cut across multiple sectors. One of the key interventions that the health sector will implement is ensuring access to comprehensive health and psychosocial services for ebola survivors. This intervention will be implemented with the Ministry of Gender, Social Welfare and Children’s Affairs. Other programmes that will be implemented with other MDAs include the Sierra Leone Health Insurance (with Ministry of Labour and Social Security); Provision of water as part of the WASH services (with Ministry of Water Resources); Provision of power supply to health care facilities (with Ministry of Energy) etc. 10.6 Improved policy and legal environment An enabling operating environment is necessary to ensure successful implementation of both the health sector recovery plan and fully implement the basic package for essential health services. The Ministry of Health and Sanitation will work with partners to update the required policies, standards and guidelines health to prepare for an integrated delivery of BPEHS at all levels. This work will start as early as during the Getting to Zero and transition period and continues through the recovery plan period.COSTING & FINANCING11.1 Costing With support from the World Health Organization, the country embarked on a costing exercise using a tool that was assessed among others and found to be suitable for the Sierra Leone context. WHO fielded a team of four costing experts to Sierra Leone over a period of 6 weeks with specific and clear terms of reference. The OneHealth tool was used to develop three investment scenarios to determine the impact of the duration of investment on the resources needed for implementing the health sector recovery plan. A full report on the costing, including the costing team, the costing methodology and impact analysis is presented in Annex 1 of this investment plan. The summary of the considerations for the three scenarios are presented below followed by three tables specifying the required financial resources by year, one for each scenario. 11.1.1 Baseline ScenarioIn this scenario, the coverage for HR and other inputs as well as the Essential Health Services continues with the 2014 targets maintained resulting in limited implementation of the BPEHS. In this scenario, facility improvement was not implemented including the upgrade of Regional Hubs.Moderate ScenarioIn this scenario, the coverage target for HR and BPEHS Services were scaled to achieve the pre-EVD levels in 2015 and then increased rapidly to the proposed target by 2020 in alignment with the recovery and resilience strategy of the plan. The “S” shaped implementation curve was used. The “S” shape curve assumes initial slow implementation followed by a rapid rise in scale-up of services before the rate of growth in scale plateaus off towards the end of the strategic period. In this scenario, facilities improvement was implemented in addition to the upgrade of the Regional Hubs. 11.1.3 Aggressive Scenario All the interventions were scaled to the proposed target from 2015 to the target year 2020 using the frontloaded scale –up profile. In this scale-up profile, implementation scale-up proceeds at a rapid rate initially in order to ensure the rapid reversal of the prevailing impact of EVD on the Health Services, System and Mortality indices of the health sector. Facilities improvement was implemented in addition to the upgrade of the Regional hubs in this scenario.11.2 Financing the health sector recovery planThe health sector recovery plan will be financed through a combination of domestic sources from MOFED or by donor partners. A mapping on funds available in the country was conducted and donors were requested to state their commitments over the next Medium Term Expenditure Framework (MTEF). In addition, the health sector worked with MOFED to determine the commitments by the Government of Sierra Leone to the health sector over the next MTEF. Below is a table indicating funds availability for the health sector recovery plan from Government sources. Information from donors was not complete at the time of finalizing the recovery plan. Table 2: MTEF from Ministry of Finance and Economic Development LINK Excel.Sheet.12 "C:\\Users\\CShilumani\\Desktop\\New folder (3)\\MTEF_24March2015.xlsx" Sheet1!R1C4:R24C9 \a \f 4 \h \* MERGEFORMAT MTEF (Le millions)Exchange Rate4,500YEARTYPECENTRALUSD EQUIVALENTTRANSFER TO LOCAL COUNCILSUSD EQUIVALENT2015RECURRENT87,167$19,370,44420,297CAPITAL: DOMESTIC54,837CAPITAL: FOREIGN 100,429CAPITAL TOT155,266YEAR TOTAL242,433$53,874,00020,297$4,510,4442016RECURRENT98,062$21,791,55622,835CAPITAL: DOMESTIC70,178CAPITAL: FOREIGN 210,178CAPITAL TOT280,356YEAR TOTAL378,418$84,092,88922,835$5,074,4442017RECURRENT110,318$24,515,11125,689CAPITAL: DOMESTIC192,113CAPITAL: FOREIGN 184,930CAPITAL TOT377,043YEAR TOTAL487,361$108,300,22225,689$5,708,667TOTAL OVER THREE YEARS1,108,212$246,267,11168,821$15,293,556GRAND TOTAL$261,560,667Table 3: Baseline ScenarioSummary costs (United States Dollars) - SIERRA LEONE_HEALTH SYSTEM RECOVERY & RESILIENCE PLAN _baseline_Skilled Total costs201520162017201820192020TotalTotal Programme Costs$8,793,050$7,354,047$5,531,337$6,300,902$4,753,181$5,984,867$38,717,384Total Medicines, commodities, and supplies$29,641,091$29,752,376$31,045,536$30,454,867$30,805,009$31,914,776$183,613,655Total Logistics$26,421,122$26,421,122$26,421,122$26,421,122$26,421,122$26,421,122$158,526,732Total Health Information Systems$6,189,589$2,233,036$5,708,891$2,577,921$2,464,553$3,246,100$22,420,089Total Governance$30,216$29,354$32,355$33,634$33,727$34,657$193,943Subtotal$71,075,068$65,789,933$68,739,241$65,788,446$64,477,591$67,601,521$403,471,803Total Human Resources$26,421,122$26,421,122$26,421,122$26,421,122$26,421,122$26,421,122$158,526,732Subtotal$26,585,765$28,496,758$35,491,502$42,544,181$44,455,174$44,619,818$158,526,732Total Infrastructure$3,088,916$3,587,767$3,652,134$3,813,054$3,523,399$3,335,659$21,000,929Grand Total$100,749,749$97,874,458$107,882,877$112,145,681$112,456,164$115,556,998$582,999,464Table 4: Moderate ScenarioSummary costs (United States Dollars) - SIERRA LEONE_HEALTH SYSTEM RECOVERY & RESILIENCE PLAN _Moderate_Skilled Total costs201520162017201820192020TotalTotal Programme Costs$8,793,050$7,354,047$5,531,337$6,300,902$4,753,181$5,984,867$38,717,383Total Medicines, commodities, and supplies$23,265,007$26,590,474$37,743,993$48,852,631$54,196,688$57,732,751$248,381,544Total Logistics$26,478,101$26,539,777$26,605,538$26,675,688$26,750,558$26,830,504$159,880,166Total Health Information Systems$6,189,589$2,233,036$5,708,891$2,577,921$2,464,553$3,246,100$22,420,089Total Governance$31,452$34,773$41,963$44,861$46,238$42,525$241,811Subtotal$64,757,198$62,752,105$75,631,721$84,452,004$88,211,217$93,836,746$469,640,992Total Human Resources$26,585,765$28,496,758$35,491,502$42,544,181$44,455,174$44,619,818$222,193,199Subtotal$26,585,765$28,496,758$35,491,502$42,544,181$44,455,174$44,619,818$222,193,199Total Infrastructure$13,526,885$24,694,393$28,794,494$22,586,412$21,506,600$3,335,659$114,444,443Grand Total$104,869,848$115,943,256$139,917,717$149,582,598$154,172,992$141,792,223$806,278,634Table 5: Aggressive ScenarioSummary costs (United States Dollars) - SIERRA LEONE_HEALTH SYSTEM RECOVERY & RESILIENCE PLAN _Aggressive_Skilled Total costs201520162017201820192020TotalTotal Programme Costs$8,793,050$7,354,047$5,531,337$6,300,902$4,753,181$5,984,867$38,717,383Total Medicines, commodities, and supplies$39,615,485$46,954,273$53,443,287$57,291,358$61,523,971$66,366,527$325,194,900Total Logistics$26,478,101$26,539,777$26,605,538$26,675,688$26,750,558$26,830,504$159,880,166Total Health Information Systems$6,189,589$2,233,036$5,708,891$2,577,921$2,464,553$3,246,100$22,420,089Total Governance$36,357$40,882$46,673$47,393$48,436$45,115$264,855Subtotal$81,112,581$83,122,014$91,335,725$92,893,262$95,540,699$102,473,112$546,477,393Total Human Resources$26,585,765$28,496,758$35,491,502$42,544,181$44,455,174$44,619,818$222,193,199Subtotal$26,585,765$28,496,758$35,491,502$42,544,181$44,455,174$44,619,818$222,193,199Total Infrastructure$13,526,885$24,694,393$28,794,494$22,586,412$21,506,600$3,335,659$114,444,443Grand Total$121,225,231$136,313,165$155,621,721$158,023,856$161,502,473$150,428,589$883,115,034IMPLEMENTATION ARRANGEMENTS12.1 Leadership and Governance structures As required by the health compact signed by Government and partners in 2010, national ownership and Government leadership in the implementation of the health sector recovery plan is emphasized. The Ministry of Health and Sanitation, as the Government Ministry responsible for the health of all Sierra Leoneans, will provide overall leadership and remain accountable for the implementation of the health sector recovery plan. In line with the Health Compact signed by the Ministry of Health and Sanitation and health partners in 2010, the Health Sector Coordinating Committee will support the Ministry of Health and Sanitation with high level decision making during the implementation of the health sector recovery plan. The Health Sector Steering Group and working groups will continue to support HSCC as per TOR in the health compact. The Government of Sierra Leone is asking all partners to uphold the principles of country ownership and mutual accountability in the implementation of the plan. 12.2 Operational Structures12.2.1 MOHS’ Delivery Operational TeamThe Ministry of Health and Sanitation established a Delivery Operational Team that will be responsible for managing the operationalization of the health sector recovery plan. The Delivery Operational Team is linked to the Delivery Team in the office of the President, ensuring synergies with other sectors. Through the Chief Medical Officer, the Delivery Operational Team will report on health sector recovery plan implementation progress to the health sector coordinating committee. Terms of Reference for the Delivery Operational Team will initially cover the first 6-9 months, with additional TORs developed as the sector moves along the various phases of implementation. 12.2.2 Directorate of Health Systems, Policy, Planning & InformationHaving led the health sector recovery planning process, the Directorate will be responsible for monitoring the implementation of the plan through its various units and its networks of officers at the district level. Half-yearly reviews of implementation have been provided for in this plan (see section on Monitoring and Evaluation below for details). The Health Systems Strengthening Unit within the Ministry of Health and Sanitation’s Directorate of Health Systems, Policy, Planning and Information will provide secretariat services to the Operational Team while the Director is a substantive member of the Operational Team. 12.2 3 Integrated Health Projects Administration UnitThe Ministry of Health and Sanitation re-established the Integrated Health Projects Administration Unit (IHPAU), an integral structure within MOHS that will integrate all donor-funded projects to be centrally managed. While IHPAU is responsible for ensuring quality financial management, timely procurement of supplies, and efficient monitoring of project implementation on donor-funded projects, it will work very closely with MOHS Directorates and Units including, the Director for Financial Resources, the Director for Audit, the Procurement Unit and the M & E Unit to ensure stronger collaboration across Government-funded and donor-funded projects. IHPAU will be the main custodian of donor funds allocated to the Ministry of Health and Sanitation for the health sector recovery plan. 12.3.4 District Health Management TeamsAt the district level, capacity building efforts will be prioritized to further support the effective implementation of the BPEHS by the DHMTs. This will include: regular trainings, ensuring the availability of drugs and other supplies in health facilities, improvement of health infrastructure, provision of resources to conduct outreach services, and timely payment of performance-based financing to health facilities. Joint supportive supervision will also be strengthened. There will be a strong emphasis on increasing leadership and management capacity at the district and facility levels.12.3.5 Regional Hubs In addition, as highlighted above, three regional referral hubs for quality care will be established serving as centres of excellence for catchment health infrastructure and learning base. Regional referral hubs for quality of care will concentrate highly specialised health experts enabling transfer of skills, contributing to improved patient safety, mentoring and coaching for quality of care improvement, facilitating creation of a continuum of care network from community level. Guidelines for regional referral hubs for quality of care will be developed for hospital, PHU facility and community level. Regional referral hubs for quality of care will be strengthened to ensure a critical mass of requisite specialists for skills transfer by experienced experts. These hubs will also build capacity for strengthening the community-health facility interface. 12.4 Key State Institutions 12.4.1 Health Services Commission (HSC)The HSC has a crucial role to play in the implementation of the health sector recovery plan, in particular the health workforce component of the BPEHS. The health sector recovery plan makes provision for the strengthening of the capacity of the HSC to quickly deploy health workers with an emphasis on remote areas. In addition, HSC is mandated to address the basic conditions of services, including remuneration issues. Enhanced capacity to perform this function will ensure improved health worker motivation and increased staff retention. 12.4.2 National Pharmaceutical Procurement Unit (NPPU) The NPPU is a statutory body mandated to strengthen procurement and supply chain across all levels of health care in the country. MoHS will work with partners to ensure that adequate resources are made available to make the NPPU functional. NPPU will be crucial to the timely delivery of health commodities to the end-user, rational drug use and ensuring that there is no stock outs.12.5 The role of partnersThe role of partners in the development of the health sector recovery plan is appreciated. The success of health sector recovery plan implementation will largely depend on all stakeholders working together, in alignment, toward the agreed goals and objectives. The role of the various partners supporting the health sector is indicated below.12.5.1 Donor partnersDonors provide the necessary financial resources that enable the health sector to advance on the goals of the Agenda for Prosperity and the National Health Sector Strategic Plan. Donors are key stakeholders in the health sector coordinating committee; a body that deliberate on health sector policies and provide guidance to the Ministry of Health and Sanitation make policy decisions. In addition to providing policy decision support, the health sector will rely on donors to mobilize additional resources to close the current funding gaps so the health sector recovery plan is fully funded. Donors will also play a key role in supporting the health sector to develop operational plans for recovery. 12.5.2 Technical Assistance partnersSierra Leone is fortunate to have technical support partners, especially within the United Nations family, that provide high quality technical assistance and participates in Ministry of Health policy discussions and subsequent programmes. The role of UN partners (WHO, Unicef, UNFPA, UNDP etc.), other technical agencies such as the Clinton Foundation (CHAI), Tony Blair’s Africa Governance Initiative (AGI) and others will be called upon to provide technical assistance to the Ministry of Health and Sanitation. The Ministry of Health and Sanitation will continue to have full responsibility for identifying technical assistance needs, approaching technical assistance partners as well as ensuring that all technical assistance made available is better coordinated. 12.5.3 Implementing partnersNon-governmental organizations, civil society, faith-based organizations, international organizations and other partners will also play a key role in supporting the BPEHS. Partnerships at the district level will be further strengthened through the development of Service Level Agreements (SLAs) between the Ministry of Health and Sanitation with partners, counter-signed by the District Medical Officers for the respective districts of operation. The SLA will clearly define the roles and responsibilities of all stakeholders, map out activities to be undertaken by each actor with performance standards and means of verification. The DMO will lead regular coordination meetings with all key stakeholders at the district level. The DMO will agree with the partner on the frequency of joint monitoring visits with the partners, whereas MOHS at the central level will conduct joint monitoring visits with the implementing partners and the donor agency at least twice during the lifetime of the project (mid-term and terminal) to ascertain that the performance standards as agreed in the SLA have been met. RISK ANALYSIS AND MITIGATIONWith any plan, there are risks that should be taken into consideration and as much as possible, plans put in place to minimize the impact of such events, should they occur. While not exhaustive, below are events that could occur that will have an impact on the implementation of the health sector recovery plan:Recurrence of Ebola: Evidence shows that countries that have experienced the EVD outbreak have since had resurgence of the virus. The country is very aware of this possibility and is putting mitigation measures in place, including strengthening surveillance system that includes an early warning system. Insufficient Funding: The plan is ambitious and if funded fully, will ensure that Sierra Leone’s health system is able to respond to future health emergencies. The costs are commensurate with the ambitious targets and the vision of the Ministry of Health and Sanitation. With the context of scarce financial resources, there is a possibility of delayed or limited financing for the plan. The Ministry of Health and Sanitation will work very closely with the Ministry of Finance and Economic Development to seek an increased spending on the health sector as measured by per capita expenditure on health. In addition, early engagement of donors and international NGOs who have access to financing will mitigate the potential challenges. Delays in implementation at the district level: Delays in implementation could be a result of many factors, including delays in transfer of funds from the central level to the district level or limited capacity at the district level to implement activities. Partners not aligned to the plan: In a haste to harness the quick wins, there is an inherent risk that partners may not be aligned to the health sector recovery plan. The introduction of Service Level Agreements between MOHS and the partners and joint monitoring with the donors will mitigate the challenge. Unforeseen economic crisis: Such a crisis will affect the country’s investment of its own money into the plan. In addition to the regional fund at the Mano River Union level, the country will explore establishing a contingency fund.The mitigation proposals are summarized below:RiskMitigation measuresRecurrence of EVDStrengthen surveillance systemInsufficient fundsPrioritize key elements of the BPEHSDelays in implementation at district levelWork closely with all parties including MoFED, development agencies and district-supporting NGOs to improve fund-flow to districts and strengthen DHMTs to increase absorptive capacityPartner misalignment to planReinforce the National Compact and district MoU Unforeseen economic crisesPlan for a contingency fundMONITORING & EVALUATIONBuilding on the Results and Accountability Framework (2010-2015), the MOHS Delivery Operational Team will develop a Monitoring and Evaluation framework that will track progress towards the key expected results. The M & E framework will articulate the performance indicators and targets up to 2020 with special emphasis on those that will be achieved within the next 6-9 months. In addition, the framework will describe the monitoring, supportive supervision and information needs for the health sector recovery plan. Schedule of monitoring and supportive supervision missions will also form part of the M & E framework, although it will remain at a higher level for the implementation phases beyond the 6-9 months with plans to concretize the, as implementation of the plan progresses. The primary data source for the indicators will be from the HMIS and will be supplemented by programmatic assessments, surveys, support supervision reports and studies, as needed. In addition to the central level indicators, district level indicators will be developed to facilitate regular district-level performance assessments. At the district level, DHMTs, which include M&E officers, will be responsible for regular reporting of the indicators.A final evaluation of the Sierra Leone Health Recovery Plan will be conducted to assess the overall impact of the investments and the health gains achieved over the implementation period. ................
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