HEALTH FOR ALL COALITION-SIERRA LEONE
MONITORING REPORT
COMMUNITY MONITORING OF THE FREE
HEALTH CARE SERVICES
PRESENTATION OUTLINE
1. BACKGROUND INFORMATION
2. MONITORING METHODOLOGY
3. KEY THEMATIC ISSUES
4. FINDINGS
5. RECCOMMENDATIONS
1.BACKGROUND INFORMATION
Health for All Coalition (HFAC), is a Civil Society Health Advocacy
Network, HFAC advocates for the equitable distribution of health
care delivery in Sierra Leone to all citizens.
HFAC has the mandate to monitor the free health care initiative
(FHCI) which makes provision for pregnant women, children under
five years to receive services free of charge in all government
health care facilities.
To help fulfill this mandate UNFPA, UNICEF and DFID support
HFAC to carry out effective monitoring. As a result of UNFPA,
UNICEF and Options support, HFAC now have a practical M&E
system, with health facilities equitably distributed across monitors.
To aid the data collection process, monitors are provided with
detailed guidelines on how data should be collected for indicators,
to enable the tracking of key aspects of the healthcare policy and
to ensure the policy is implemented according to plan and services
are reaching the intended beneficiaries.
The report summarizes findings for all nine components of the HFAC M and E plan.
Table below shows objectives and core indicators for all nine component considered in the
HFAC M and E plan.
HFAC Monitoring of Free Healthcare Initiative: Objectives and indicators
No Component
Objectives
Indicators
% of clinical staff on MOHS
payroll signed-in in the staff
attendance register
1
Staff attendance
To promote the integrity of staff
attendance register
% of facilities where number of
clinical staff on MOHS payroll
counted by monitor is less than
number of staff signed in at
facility
% of clinical staff on MOHS
payroll physically counted
% of staff on unauthorized leave
of absence
CONT
No
Component Objectives
Indicators
2
User Fees
Total user fees collected
To investigate the level of
accountability of user fees
collected and FHC clients’
experience with regards to
charges for services.
Total user fees spent on service provision
% of patients (entitled to FHC) charged a
fee for treatment.
% of patients (entitled to FHC) charged a
fee for drugs.
3
Drug Supply
To verify the receipt of Free % of drugs issued to patients
Health Drugs and other
medical supplies including
% of quantity of FHC drugs and supplies
consumables received at the received at public health facilities
health Facilities
4
Ambulance
services
To assess efficiency and
accountability in provision
of ambulance services
% of requests received by referral hospitals
that were responded to
% of ambulance service request by PHU
responded to
CONT.
No Component
5
6
Health facility
supervision
Nutrition
support
7
Patient
charges and
satisfaction
8
Maternal,
child and
infant deaths
Objectives
Indicators
To assess the efficiency in
supervision of health facilities
by the District Health
Management Teams
Mean Number of DHMT visits per
reporting month
To ensure nutritional
supplements reach targeted
beneficiaries
% of caregivers who report that their
child did not receive quantity of nutrients
issued as per health facility records
% of children registered on OTP verified
by household visit
To collect data on the
patient’s perception of health
services they receive at the
health facility, and on drug
and treatment charges.
To assess the efficiency and
accountability in provision of
record on Maternal, infant
and child death
% of all patients who reported seeking
services from the same facility in the
future
Mean number of child and infant (0 – 59
months) deaths for reporting month
Mean number of maternal deaths for
reporting month
2. MONITORING METHODOLOGY
At each quarterly visit, monitors are required to administer at least three sets of forms in all
1289 peripheral health unit (PHU) and 20 referral hospitals. Table 3 – lists the basic data
collection requirements by form type.
Form Type
Basic Requirements
HFAC F1 – Resource Management and To administer in each PHU quarterly
record of maternal and child deaths at
PHUs
HFAC F2 – Resource Management and To administer monthly at referral hospitals (Data to
record of maternal infant and child be collected weekly for shift 1, 2, 3 respectively – for a
deaths at Referral Hospitals
total of three forms per month)
HFAC F3 – Household verification of To administer in each health facility conducting
children registered for Outpatient outpatients therapeutic programme (OTP) quarterly,
therapeutic programme
including OTP sites in referral hospitals
HFAC F4 – Patient Satisfaction
To administer at each health facility quarterly (10 at
every PHU and 24 at each Referral Hospital)
HFAC F6 – Drugs and other medical To administer in each facility quarterly
supplies
THE FINDINGS
1. STAFF ATTENDANCE AT PHU LEVEL
• The results from 854 facilities for which complete data on this indicator were
available, indicate that in all 854 PHUs, there is a register/book for staff to sign
in when they report for work.
• 95.6% of staff working at PHU level in all the four regions signed in the register
on the date of the assessment.
•
Of the 2,097 staff posted to facilities, 1,918 (91.5%) were present at their post
on the day of the monitors visit.
• 57 of 2,097 (2.7%) of staff where absent from their post without a valid reason
on the day of the visit.
• Of the 854 PHUs only 105 facilities (12.3%) of PHUs recorded information
regarding staff movement. Record for staff movement is high in the Western
Area with about a third (33.3%) of facilities recording information on staff
movement and lowest for facilities in the eastern province with only 7% having
written evidence on staff movement.
2. STAFF ATTENDANCE AT REFERRAL HOSPITALS

About 5,009 staffs were reported to be posted in
referral hospitals 4,634(92.5%) signed-in in the
attendance register, that is 375(7.5%) staff do not
signed the attendance register at the time of the
Monitors visits.
 These figures are exceptionally high for referral
hospitals like Kailahun Government Hospital(162
posted and 137 signed –in),Kaffu- Bullum hospital(176
posted and 150 signed –in), Bo Government hospital(
637 posted and 515 signed-in), Connaught hospital(
549 posted and 497 signed –in) and Ola during
hospital( 310 posted and 258 signed-in).
RECCOMMENDATIONS
Ensure that there are at least two trained nurses attached to each PHU
so that if one leaves, the centre can stay open.
Enforce the MOHS HRH sanctions and code of conduct for health
workers and review staffs leave policies.
Train more health workers and improve their condition of service e.g.
Prompt payment of salaries, improved accommodation, in-service training
for remote staff, and early absorption into the payroll.
The MOHS need to find out where these staffs are; otherwise their
space be filled by trained un-employed nurses.

3.Maternal, Child and Infant Deaths at Referral Hospitals and
Peripheral Health Units .
Out of the 854 PHUs and 20 Government referral hospitals selected for analysis, 386 PHUs and
17 Government referral hospitals recorded data on maternal, infant and child deaths .
130 Maternal and 641 infant and /or child deaths occurred in the 386 PHUs and 17 Government
referral facilities of which data were available.
106 maternal deaths were reported in the South , 86 in the North and 80 in the East for the
period of July to September 2012 .
For the Western Area, only two PHUs had mortality data, one of the two PHUs reported one
maternal death.
PHUs in the Northern and Southern Provinces reported the highest number of maternal deaths
of 43 and 42 respectively whilst , PHUs in the East recorded 6 maternal deaths.
Maternal deaths in referral hospitals in the East is 9, 23 in the North,36 in the south and 30 in
Western area.
For the referral hospitals Bonthe and PCMH records the highest number of maternal deaths of
23 and 17 deaths for the months of July to September 2012.
Infant’s deaths are highest in PHUs in the East 80 deaths ,South 64 deaths and North 56 deaths
and there was no record of infant death reported in PHUs in the western area.
Western area hospitals accounts for more than 50 %( 361) infants deaths occurring in hospitals ,
with 49% (312) of those deaths coming from Ola During or Children’s hospitals.
There are also significant infant deaths in districts like in the South Moyamba 74, in the East
Kenema 48 and in the North Kambia 46.
HFAC monitors records that the major factors of maternal deaths are but not limited to;
Shortage or no blood in referral hospitals, late referral from communities and PHUs, poor road
network in hard to reach areas, lack of electricity supply in facilities, Non-availability of
ambulances as a result of fuel, poor communication systems, no maintenance costs for
ambulances, low family planning uptake, Malnutrition and poor community knowledge of
danger signs during pregnancy.
The most common reasons for infants deaths as reported by community monitors includes but
not limited to; diarrhea, measles, fever, Malaria, anemia, late referral by communities and PHUs
staff, poor road network in hard to reach terrains and malnutrition.
RECCOMMENDATIONS
Develop national policy on Traditional birth attendants, home deliveries and the strengthening of the referral system.
Enforce maternal death data recording by Referral hospitals and PHUs
Develop and enforce community byelaws on home deliveries.
Invest in the quality of care in the referral hospitals.
Scale up Family planning education, information and communication both in schools and communities
Scale up nutrition education, information and communication in schools and communities.
4.USER FEES
Out of the 865 PHUs, Only sixty four 64 (7.5%) reported having a cashbook to
document user fees collected.
Facilities surveyed in the western Area Rural, Kailahun, and Kono does not
maintain a cashbook.
The total amount of money collected by all 64 facilities having cash book was
found to be le 14,158,500 Leones.
The pattern of expenditure of user fees varies by district. Koinadugu, Portloko
and Pujehun districts reported the highest expenditure, spending over 70% of
the user fees collected.
Overall, only 69.7% of the total money collected by the facilities was spent
across the districts.
An unusual pattern was observed for Kambia district. The total funds recorded
as spent ( le1,219,000 Leones) exceeded the total funds collected ( le1,104,000
Leones).
RECOMMENDATIONS
• Government of Sierra Leone should scale up the
procurement and distribution of cost recovery
drugs to public health facilities.
• Set up and enforce transparent and accountable
mechanisms for the management of cost recovery
drugs that will include use of cash books/record
books for all public facilities.
• Enforce the display of cost recovery drugs price list
in all public facilities
5.PATIENT SATISFACTION
Patients receiving services on the day of the monitor visit including those
eligible for free health care services were interviewed to find out whether they
were requested to pay for services.
Of the 10,178 beneficiaries interviewed in 854 facilities, 7,125 are FHC
patients and 3053 are non-FHC patients.
188 of 7,125 FHC beneficiaries entitled to FHC services reported paying for
treatment and 251 reported paying for drugs.
The total amount collected from FHC beneficiaries was just over 5 million
Leones- (1,777,000 Leones for treatment and 3,279,300 Leones for drugs).
According to the beneficiaries eligible for free health care, service providers
requested for payment for immunization services, and for treatment of malaria
and diarrhea. Where as some pregnant women receiving antenatal care and
also those seeking post natal care were asked to pay for services.
RECOMMENDATIONS
Develop and implement strong sanctions
against any worker that takes money or any
form of inducement from FHC beneficiaries
6.Drugs and Medical Supplies
Drugs and supplies from Central Medical stores(CMS)
to District Medical stores(DMS)
Almost 100% (61,918,477 of 61,921,527) units of FHC
drugs were received at district medical stores. 96.9% of
those are essential drugs, 1.6% anti-malaria, 0.9%
contraceptives, 0.4% consumables, 0.004% kits, 0.3%
supplies and 0% plumpy nuts.
During this period no plumpy nuts were supplied from
CMS to DMS. However, HFAC drug monitors at the CMS
reported that plumpy nuts were supplied from different
stores other than the CMS and these supplies were not
entered into CHANNEL.
Significant improvement was observed in the supply and
management of drugs at the central medical stores.
Cont
DRUGS AND MEDICAL SUPPLIES FROM THE DISTRICT MEDICAL STORES(DMS) TO PEREHEREAL
HEALTH UNITS(PHUs)
During this period, 13,961,127 units of drugs were dispatched to PHUs and they received
14,055,329 units of drugs. This means that 0.7% (94,202) units of drugs were received in excess
in PHUs.
Out of the 854 facilities from which reliable data were collected and analyzed, Essential drugs
accounted for 91.9% of the drugs supplied to PHUs, followed by 3.1 %, Anti-Malaria, 2.5%
contraceptives and 2.3% plumpy nuts
At the time of the Monitors Visit only 74% (12,127,838.5) units of drugs were recorded to have
been issued to patients.
A total of 316,210 sachets of plumpy nuts were dispatched to PHUs, but they only received
311,374 sachets, this means 1.5% (4,836 sachets) were not received at PHUs. With the
exception of Kits and plumpy nuts; essential drugs, Anti-malaria, contraceptives and
consumables were received in excess quantities at facilities.
The reasons given by monitors for the excesses was that drugs were supplied to facilities but not
recorded in the dispatching waybill and some drugs were recorded in waybill but short in
quantity at the point of delivery.
Stock-out of drugs is highest for contraceptives 56 %( 478 facilities), followed by Anti-malaria 53
%( 455 facilities) and essential drugs 45.4% (388 facilities).
CONT.
In the Eastern Region almost 100% of drugs supplied to PHUs were received as
compared to the South and Western area Rural and Urban where facilities
received more drugs than recorded in the dispatch waybill.
In the Northern Region, Bombali and Koinadugu received almost all the drugs
supplied to their facilities, whiles Kambia, Portloko, and Tonkolili districts
received drugs at their facilities in excess quantities.
Kambia district and Western area Urban account for the highest amount of
discrepancy of drugs supplied to PHUs of about 18.5% (46,562) and 3.2 %
(40,036) excess amount of drugs received
Some quantities (102,390 units) were also supplied to private and or faith
based health facilities.
Overall, HFAC Major improvement in the management and distribution of
drugs from DMS to PHUs for the reporting period. However, there are still
major issues to be addressed in the distribution of drugs from district medical
stores to PHUs.
RECOMMENDATIONS
Strengthen collaboration and coordination among MoHS and other
stakeholders including Civil Society Health For All Coalition in the supply chain
management of drugs and other medical
Strengthen the district medical stores for an improved management
,distribution of drugs and medical supplies to PHUs including assigned drug
distribution vehicles to the stores management.
Clarify and enforce the policy around cost recovery drugs and their use for FHC
beneficiaries and put appropriate mechanisms for the management and
accounting of cost recovery drugs.
Strengthen the management capacity of Central Medical stores, and district
medical stores and both in human resources and logistics.
Enforce policies to ensure that incharges provide regular returns at the
appropriate time
7.Ambulance Services
About 40% (345 of 854) of PHUs maintained a record book documenting
ambulance request or response data.
In Western Area out of 42 PHUs visited by monitors only 28 PHUs provided
recorded on ambulances and in the Southern region out of the 274 PHUs
visited only 92 provided records on ambulance services . Whereas facilities
in the Northern region out of 340 PHUs visited 140 provided record on
ambulances and in the Eastern Region out of 198 PHUs visited only 85 PHUs
provided record on ambulance services.
PHUs in the western area made 57 requests of which 52 were responded to
and in the southern region 185 requests were made and 170 responded to .
Whereas in the northern region 139 requests were made and 122 responded
to and in the eastern region 107 requests were made 95 responded to.
90% of PHUs documenting ambulance data, reported that referral hospitals
are generally responsive to ambulance requests.
RECOMMENDATIONS
A separate budget line be created for the
maintenance of ambulances at national and district
level.
Ensure that at least three (3) functional ambulances
are available at district referral hospitals.
Ensure the timely and sustainable provision of fuel
for ambulance services at all levels.
Enforce the use of ambulance request and responds
books in all PHUs.
Enforce the guidelines on the use of the ambulance
Health Facility Supervision
On average DHMTs visited facilities at least twice
a month (mean visit per month =2.0).
RECOMMENDATIONS
The DHMTs to intensify supportive supervision
visits to public health facilities.
Sustainable and timely Provision of funds and
logistics for DHMTs supervision
CONCLUSION
The first and the second years in the implementation of the FHCI has shown
some improvements, most notably the increased utilisation of Government
health facilities by pregnant women, lactating mothers, and children under
five, Improvement in the drug distribution system to districts, increased
number of health workers recruited, gradual improvement in condition of
service of health workers, low % of beneficiaries paying for drugs and
services and improvement in the ambulance services .
This is a vital step towards reducing the infant and maternal mortality rate
in Sierra Leone. However, there is still much work to be done in
strengthening the health services and enabling the people of Sierra Leone
to access the quality of health care they have a right to receive.
In order for the FHC to be sustained and continue to be meaningful to the
people of Sierra Leone ,HFAC recommend that Government and
development partners invest more in family planning and nutrition for
improved Maternal and Child health.
THANK YOU !