ReliefWeb

GRANT AMOUNT: IDA-US$20.0 million equivalent
PROJECT DESCRIPTION: This project's overall development objective is to help restore the most essential functions of the health delivery system of Sierra Leone. The project will also help achieve the more specific objectives of: (i) increasing access to affordable essential health services by improving primary and first referral health facilities in four districts of the country; (ii) improving the performance of key technical programs responsible for coping with the country's major public health problems; (iii) strengthening health sector management capacity to improve efficiency and further decentralize decision-making to the districts; (iv) supporting development of the private health sector and involvement of the civil society in decision-making. For more information, please call Raymond Toye at 202.458.1653, fax at 473.7917, or e-mail rtoye@worldbank.org. To view the project information documents, please see below or visit
http://www4.worldbank.org/sprojects/Project.asp?pid=P074128

Last Updated February 25th, 2003

Basic Information

1. Country and Sector Background

At the end of a decade of war, political and social instability, and deterioration of the economic performance of an otherwise well-endowed country, the health sector in Sierra Leone is facing many issues.

a) The health status of the population is, compared with other SSA countries, critical; it is estimated that life expectancy at birth is only 43 years, and infant, under-five and maternal mortality rates are as high as 170, 286 and 18 per 1000 live births respectively. The country is plagued by diseases for which cost-effective interventions are available but are not being used due to: (i) problems with resources of all kinds (financial, infrastructure and especially human resources); (ii) weak sector capacity, and; (iii) limited access to some geographical areas because of the security situation (until very recently), poor roads and inadequate communications. Among these diseases are malaria, tuberculosis, leprosy, acute respiratory diseases, diarrhea, Lassa fever, onchocerciasis, and cholera and other water borne diseases. Also, compared with neighboring countries, the HIV/AIDS epidemic is more significant; the prevalence rate of HIV sero-positivity is now estimated at about 4.9w (the CDC Atlanta base line survey of 2002) and may reach 18t in some groups (e.g., military). As a result of war atrocities, the country was left with thousands of amputees; a huge number of psychologically affected people (mostly women among whom many were raped and/or lost their children and families; and children who are orphaned or living away from their parents. Fertility rates are also high as a result of insufficient use of contraception, particularly in rural areas.

Lastly, malnutrition is widely spread among children and lactating mothers and contributes significantly to the high mortality rates cited above.

b) The health delivery system is operating poorly. During the conflict, the country is estimated to have lost more than 50t of health facilities and the remaining facilities need rehabilitating, re-equipping, new staff, and technical and financial support. While the recent conflict exacerbated the situation by destroying health facilities and displacing (or worse) staff, the public health sector has not performed well for more than a decade; with inadequate financing, MOHS could not supervise and support technically the public health facilities country-wide. Further, the destruction of the infrastructure of other sectors affected, and continues to affect, the health sector's operations since communications, transport, electricity, water supply, etc., were also severely disrupted.

Many international and local NGOs specialized in providing health care during conflict and in post-conflict situations have successfully delivered services to the districts in which the public health facilities were not able to operate. In addition, NGOs are contributing substantially to alleviating psychological suffering and providing physical rehabilitation to amputees. As a result of the progress in peace negotiations and increased security, these NGOs are now in the process of phasing out their aid programs. Other NGOs (and particularly the religious NGOs), which had previously played an important role in the delivery of health care in rural areas, suffered severe damage in the war (of 47 mission facilities in operation before the 1997 coup, only 20 are currently functioning), the mission hospitals have lost their expatriate medical staff, and the current free drug policy (applied in some government facilities and by the large international NGOs) is drawing patients away from their clinics which continue to use cost recovery (and to also successfully exempt the poor from it).

The private for profit health system, although recently developing, remains weak and limited to the Western Region and the capital city.

This makes restoration of a functioning public health sector a crucial priority for the country. At present the most important challenges for the public health sector are to find solutions for:

(a) the lack of infrastructure, especially in the districts most affected by war;

(b) the limited administrative capacity of the public sector and its persistent inefficiencies;

(c) the lack of human resources (resulting from (i) staff attrition, (ii) inadequate training (undergraduate, postgraduate and continuous on the job training), (iii) emigration of medical doctors (in particular, of specialized physicians) to developed countries; (iv) distorted geographical distribution of health workers (during the war the health providers left the unsafe zones and came to work in Freetown); and the lack of skill and motivation of the remaining health personnel.

(d) the lack of capacity of the private for profit health sector and its inability (or unwillingness) to address major public health problems.

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