WORLD HEALTH ORGANIZATION
6 March 2001
I.
CURRENT HEALTH SITUATION IN SIERRA LEONE
General Situation
1.1
Escalated rebel activity since May 2000 has hindered access to large areas of Sierra
Leone, making the collection and verification of countrywide figures for the total
internally displaced population difficult. Humanitarian agencies often refer to registered
IDPs when providing figures, but a large number of non-registered IDPs live with host
families or in hiding. The UN system had registered an IDP caseload of 341,205 by midNovember 2000 – about two-thirds of these were registered after the conflict escalated in
May 2000 (OCHA 13 November 2000).
In addition, the UN indicated in November that there were approximately one million
internally displaced Sierra Leoneans that had not been registered. (UN November 2000,
p.129). The majority of registered IDPs have sought refuge in the Tonkolili District
(including the Mile 91 area), the Port Loko District (including the Lungi area), as well as
urban areas that offer some protection from rebel attacks, e.g the Freetown area, Kenema
Town and Bo Township (OCHA 13 November 2000).
1.2
Currently long-exiled Sierra Leonean refugees are being repatriated by boat from Guinea
at a rate of 2,000 to 2,500 a week due to conflict in Guinea, bordering Sierra Leone. In
Sierra Leone itself, their compatriots are fleeing the border province of Kambia which is
controlled by the Revolutionary United Front (RUF) and under almost daily airborne
attacks from Guinean forces.
Almost 17,000 returnees have now moved into Lokomassama Chiefdom, inland from
Lungi, adding to between 10,000 and 15,000 people internally displaced in recent months
from Kambia. The returnees are being resettled in existing villages under a new model of
community absorption which the government and UN agencies hope will avert
dependency problems associated with camps and improve conditions for host
communities. With the displaced, they have increased the chiefdom's population of more
than 50 percent and, though food distribution and community facilities such as schools
and public latrines are being supported, health facilities and staff are not receiving the
same attention.
Health Situation
1.3
Sierra Leone's child and maternal mortality rates of 316 per 1,000 live births and 1,800
per 100,000 live births respectively are among the highest in the world. The health
system has been devastated by the nine-year civil war. Resumption of hostilities in May
2000 once again cut off the Northern Province and parts of the Eastern Province from
access to basic health services. The Ministry of Health and Sanitation (MOHS) lacks the
financial resources and infrastructure to deliver adequate health services to the population
even in accessible areas.
Only 38%, or 277 out of 730 Peripheral Health Units (PHUs) and 70% of the district
hospitals are presently functioning. Mass displacement of the population in safer areas
and the emigration of trained staff have put an additional burden on these few functioning
facilities.
In the year 2000, UNICEF supported 63 of the functioning PHUs while WHO supported
five district referral hospitals. NGOs supported approximately 140 PHUs and several
hospitals. As the major components of their projects, the World Bank and ADB credits
to the health sector targeted rehabilitation and the equipping of district hospitals. This
support is however contingent upon the fulfilment of a number of conditions, many of
which are yet to be met, making it less likely that the intended rehabilitation will be
realised in the immediate future. Furthermore, the extent of the damage is such that
additional funding will be needed to complement the World Bank and ADB inputs.
FUNCTIONALITY OF PHUs COUNTRYWIDE
District
Western Area
Bo
Bonthe
Moyamba
Pujehun
Kailahun
Kenema
Kono
Bombali
Kambia
Koinadugu
Port Loko
Tonkolili
TOTAL
PHUs PreConflict (1990)
62
66
32
59
41
58
85
65
63
23
35
72
69
730
Currently
Functioning
PHUs
26
53
18
52
19
2
46
2
0
14
5
32
8
277
% of Total
41.9
80.3
56.3
88.1
46.3
3.4
54.1
3.1
0.0
60.9
14.3
44.4
11.6
37.9
PHUs include CHCs, CHPs and MCHPs
1.4
Environmental sanitation facilities, especially in areas of IDP concentration, are poor due
to overcrowding resulting in high morbidity of water and air-borne diseases. Insecurity
and logistical constraints have hampered the regular provision of drugs and medical
supplies to PHUs. In the first four months of 2000, the MOHS surveillance system
reported malaria as the leading cause of morbidity from among the 19 diseases targeted
for routine surveillance. It accounted for 49% of the total disease burden followed by
acute respiratory infections, which accounted for 31%, and by diarrhoea and dysentery at
1.1%.
1.5
Reports from the National AIDS Control Programme indicate that HIV sero-prevalence
rates for pregnant women have risen sharply from 0.2% to 7% in 1998. According to the
WHO supported Surveillance Unit of MoHS, for the period May-July 2000, 56 lassa
fever cases with 5 deaths and 1,856 cases of shigellosis (bloody diarrhoea) were reported.
Yellow fever reappeared, with outbreaks in August 2000, in some areas close to the
border with Liberia.
1.6
A dramatic drop in immunization coverage rates occurred during the past nine years.
Coverage of children fully immunised at the beginning of the nineties was 75%.
However, according to reporting forms received from accessible districts in the year
2000, the percentage of children 0-12 months currently vaccinated against childhood
diseases is 47% for BCG, 30% for DPT/Polio 3, and 51% for measles. Sporadic
outbreaks of measles have been reported in parts of the north and east where routine EPI
activities have been interrupted or non-existent for up to eight years. Expansion of
routine immunisation activities has been hampered by difficulties in establishing
effective cold chain in many areas due to security and logistic problems.
The table below presents the number of children vaccinated for polio during NIDs in
1999-2000. The increase in the number of children vaccinated for polio during NIDs
from 627,978 in October 1999 to 826,913 in all districts in April 2000, illustrates
progress made in gaining access to all areas of the country following the signing of the
Lome Peace Accord. The resumption of hostilities has been a setback, but the Polio
Eradication Campaign has resumed in accessible areas and efforts to reach children
behind rebel lines will continue.
CHILDREN VACCINATED FOR POLIO DURING NIDs 1999-2000
Accessible
Districts
Less
Accessible
Districts
Total
October
1999
521,587
November
1999
588,574
December
1999
591,036
March
2000
540,591
April
2000
578,420
April 2000
compared
to October
1999
111%
106,391
113,170
185,637
246,365
248,493
234%
627,978
701,744
776,673
786,956
826,913
132%
Accessible:
Port Loko, Kenema, Bo, Pujehun, Moyamba, Bonth, Tonkolili and
Western Area
Less Accessible:
Kambia, Bombali, Koinadugu, Kono and Kailahun
1.7
Many cases of abductions; sexual violence against women and girls, including rape;
unwanted teenage pregnancies and unsafe abortions; low condom use and risky sexual
behaviour have presented increased risks for transmission of HIV and STDs as well as
increased maternal morbidity and mortality rates. An estimated 1,000 people nationwide, including women and children, have had their limbs amputated. There has also
been an increase in mental disorders, particularly among youths and adolescents.
1.8
The nutritional status of children has shown improvements in stable areas such as Bo,
Freetown, and parts of Kenema, where therapeutic and supplementary feeding centres
have been operated by NGOs. Nevertheless, the number of children needing nutrition
rehabilitation is still high. In August 2000, 5300 malnourished children were registered
for supplementary feeding and 600 received therapeutic care. This is due to an intensive
screening and referral system operating within accessible districts. No data is available
for the inaccessible areas but the poor food security situation of households, combined
with the absence of a health service delivery system, suggest that pockets of severe
malnutrition are likely in areas that are still inaccessible to humanitarian aid agencies.
The capacity of referral hospitals in all accessible districts needs to be strengthened for
therapeutic case management of severely malnourished children.
Anaemia is a problem for 86% of pregnant women with severe implications for safe
motherhood, immunity, growth and development of children. It is estimated that the
percentage consumption of iodised salt dropped from 75% in 1996 to 26.7% in 1999.
The weakness of the disease surveillance system has led to late detection of disease
outbreaks such as shigellosis and the spread of lassa fever into the Western Area.
II.
WHO ACTIVITIES – SUMMARY
2.1
Although the WHO Sierra Leone Country office carries out activities under Regular
Budget support in 15 Areas of Work (AoWs – see annexes), more that 80% of activities
are in fact related to one of six priorities areas which were agreed on in mid-1999. These
are:






Reproductive Health/Maternal Mortality Reduction
Malaria Control
Control of other epidemic diseases and surveillance
Control of HIV/AIDS
Eradication of polio
Improvement of health situation monitoring
2.2
WHO in Sierra Leone has been successful in developing collaborations with variety of
partners (NGOs and other UN agencies) which has resulted in a leverage effect for WHO
resources and increased impact. Examples of partnerships operating during 2000are:
2.2.1 Joint programming with UNFPA and UNICEF leading to creation of Reproductive
Health Unit in MoHS, which supports the WHO priority of maternal mortality reduction:
WHO concentrates on the hospital and emergency obstetrics components, including
facility rehabilitation, emergency obstetrics, anaesthesia and obstetrical nursing training
and re-equipping of vandalized facilities.
2.2.2 Joint proposals in the 2000 UN Consolidated Appeal Process (CAP) with UNICEF, FAO
and UNFPA (district health systems, epidemic and vaccine-preventable disease
surveillance and control, reproductive health, HIV/AIDS): These joint proposals exploit
the comparative strengths of each collaborating agency, and are quite attractive to donors,
who want to see synergism of this kind.
2.2.3 Hospital management restructuring and financial reform with MSF-Belgium (Bo
Government Hospital), and with International Medical Corps (Lungi Government
Hospital): Using NGO financial and material support for "leverage", comprehensive rerestructuring of hospital operations is undertaken and community-based hospital
management committees with formal oversight powers are constituted. Discussions are
underway with MERLIN
and International Committee of Red Cross (ICRC) to
introduce similar managerial reforms in Kenema Government Hospital. It is interesting
that NGOs who typically limit their mandate to "emergency" work have been willing to
take on hospital management reform in order to deliver critical secondary and tertiary
emergency services. In our view, the finding that substantial health sector reform in the
form of restructured managerial and financial controls, creation of true hospital
management boards with community participation and genuine oversight powers can be
carried out even in the midst of a complex emergency situation is new and important
information. Our Health Economist has been invited to UNHQ in New York in February
2001 to present these findings.
2.2.4 Development of lassa fever management guidelines and implementation of case
management and barrier nursing training with MERLIN; technical support for field
investigation of lassa fever cases with UNAMSIL Force Medical Office (see ter Meulen J
and Aldis W.L.: Lassa Fever in Sierra Leone: UN peacekeepers are at risk. Tropical
Medicine and International Health 2001; 1:83-84 for a description of this work).
2.2.5 Containment vaccination strategy for yellow fever with MSF-Belgium, MERLIN, and
MSF-France to prevent epidemics in Liberia and Guinea from spreading into Sierra
Leone, under direction of DPC Medical Officer.
2.2.6 Development of regular epidemiological bulletins in collaboration with MoHS.
2.3
EB funds have been successfully deployed for support to the National AIDS Control
programme ($150,000), although we are not entirely satisfied with the management or
financial controls of the NACP (see recommendation on HIV/AIDS below). The other
major EB activity has been WHO's joint collaboration with MoHS, UNICEF, and Rotary
for polio eradication. In addition to providing major funding to the NIDs and AFP
surveillance components, WHO also gave strong technical support (more than 40 manmonths of external consultant support during the reporting period), and took the lead in
negotiating directly with rebel groups for access into RUF-controlled areas during the
October and November 2000 NIDs rounds
2.4
Summary report on epidemiological surveillance, prevention and control of epidemics in
Sierra Leone using Italian funds is annexed.
2.5
WHO health team members carried out several field assessments in regard to health
needs of IDPs, returnees and local affected population (see reports).