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 ComponentObjectivesIndicators 1Staff attendance To promote the integrity of staff attendance register % of clinical staff on MOHS payroll signed-in in the 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 ComponentObjectivesIndicators 2User FeesTo investigate the level of accountability of user fees collected and FHC clients’ experience with regards to charges for services. Total user fees collected 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. 3Drug SupplyTo verify the receipt of Free Health Drugs and other medical supplies including consumables received at the health Facilities % of drugs issued to patients % of quantity of FHC drugs and supplies received at public health facilities 4Ambulance 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 ComponentObjectivesIndicators 5Health facility supervision To assess the efficiency in supervision of health facilities by the District Health Management Teams Mean Number of DHMT visits per reporting month 6Nutrition support 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 7Patient charges and satisfaction To collect data on the patient’s perception of health services they receive at the health facility, and on drug and treatment charges. % of all patients who reported seeking services from the same facility in the future 8Maternal, child and infant deaths To assess the efficiency and accountability in provision of record on Maternal, infant and child death 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 TypeBasic Requirements HFAC F1 – Resource Management and record of maternal and child deaths at PHUs To administer in each PHU quarterly HFAC F2 – Resource Management and record of maternal infant and child deaths at Referral Hospitals To administer monthly at referral hospitals (Data to be collected weekly for shift 1, 2, 3 respectively – for a total of three forms per month) HFAC F3 – Household verification of children registered for Outpatient therapeutic programme To administer in each health facility conducting outpatients therapeutic programme (OTP) quarterly, 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 supplies To administer in each facility quarterly
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.