From Research to Road Map: Learning from the Arms for Development Initiative in Sierra Leone

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Selected projects. Geographic area.

View projects. The political relevance of the challenge tackled. The innovative character of the solution or tool submitted. The diversity and number of the stakeholders involved. The stage of development. The feasibility. The scope of the impact. The potential for development, expansions, or replication. Overall, a total of households across villages were surveyed in the riverine and households across villages were sampled on the mainland.

Women across the two regions self-reported significantly different uptake of family planning services. Households on the mainland also reported significantly greater use of treated water and unrestricted access to a latrine. If the government of Sierra Leone is going to deliver on their promise to free health care for pregnant women and their children, and do so in a way that reduces inequalities, greater attention must be paid to the existing service delivery gaps within each District.

This is particularly relevant to health policy post-Ebola, as it highlights the need for more contextualised service delivery to ensure equitable access for women and children. Consistently ranked among the countries with the highest maternal mortality ratio deaths per , live births [ 1 ], Sierra Leone remains one of the worst places on earth for women to give birth [ 2 , 3 ]. It is estimated that one in every 23 women risk dying during pregnancy and childbirth [ 4 , 5 ], with many more at risk of complications and lifelong health consequences.

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In addition to poor maternal health indicators, child morbidity and mortality indicators are also cause for concern with an estimated child, infant and neonatal mortality of , and 50 per live births, respectively [ 1 , 6 ]. The causes of high rates of maternal and child mortality are multiple and complex, and likely compounded by the fact that the country is still emerging from the effects of a decade-long civil conflict and the devastating effects of the most recent Ebola oubreak.

As part of the FHCI, 1. Hailed by many at the time as an important step towards improving maternal and child health [ 7 ], early reports were quick to highlight the immediate impact of this initiative. Despite the increase in women and their children accessing health services, there is still good reason to question the sustainability of the FHCI. In , only three obstetricians were registered with the MOHS [ 3 ]. Overburdened health staff struggle to keep up with an increasing demand for services and essential medicines [ 10 — 12 ].

With drugs often in short supply, health staff often result to sending patients to buy medicines elsewhere, or charging patients for drugs as a means of cost-recovery [ 13 ]. Such out-of-pocket expenditures for women and children go against the very essence of the FHCI and calls to attention that though Sierra Leone has managed to increase the absolute number of women and their children accessing health centres, this does not necessarily translate into reducing inequities in service provision.

This is consistent with other progress seen in reducing under-five mortality, where improvements are distributed differently across wealth quintiles [ 14 ]. The inequitable distribution of health services and health facilities, a severe lack of health equipment and essential medicines, as well as a shortage of skilled and motivated health staff remain key factors underlying the poor performance of health systems to deliver effective maternal and child health care services in Sierra Leone [ 13 , 15 , 16 ].

There is a need to better understand how the FHCI policy impacts on health inequities in Sierra Leone, and more specifically how this translates into practice and interventions at the community-level. The purpose of this study was therefore to identify current gaps in service delivery across two rural locations, both of which are served by the same District Health Management Team DHMT.

The results of this study were used to inform local policy and adapt maternal and child health programming to better address inequities in health services delivery in Bonthe District. Located on the southern-most coast of Sierra Leone, Bonthe District is comprised of 11 chiefdoms and one municipality. One of 13 medical districts in Sierra Leone, Bonthe District serves a population of approximately , people [ 17 ] and is divided into two main geographical regions: the mainland and the riverine.

Both the riverine and mainland are marked by topographical, economical and administerial differences. While the entire district contains many rivers, estuaries, and lagoons, the riverine is particularly difficult to access by road. Moreover, three of the chiefdoms Sittia, Dema, and Kwamebai Krim and Bonthe Municipality, all in the riverine, are only accessible by boat. The topography of Bonthe District predisposes many of its inhabitants to waterborne illnesses including cholera and other diarrhoeal diseases, typhoid, dysentery, schistosomiasis and trachoma, malaria and river blindness.

The terrain and remoteness of Bonthe District make it particularly difficult to recruit and retain health workers and as a result, the district is severely understaffed. Administratively, two local government councils govern Bonthe District: Bonthe Municipal Council, located in the riverine and the Bonthe District Council, located on the mainland in Mattru Jong. In addition to funding from the GoSL, health centres across both regions receive considerable external support from a number of international and non-governmental organizations.

This paper examines where the key gaps exist in the delivery of essential maternal and child health services in Bonthe District. Named the 7—11 strategy, these health intervention messages are delivered through a minimum of ten household visits by a community health worker CHW. A two-stage probability sampling method was applied to obtain a sample of the population across in the riverine and on the mainland.

In the first stage of sampling, a list of all the villages from selected chiefdoms of the mainland and villages of the selected riverine chiefdoms was compiled. The probability of a village being selected was therefore set as proportional to the number of households within that village.

In this first stage, all 12, households on the mainland and households in the riverine therefore had an equal chance of being selected regardless of whether they contained the target population or not. This resulted in a minimum target of households in the riverine, and households on the mainland.

From Research To Road Map: Learning From The Arms For Development Initiative In Sierra Leone 2006

A random number generation table was subsequently used to decide which household was to be visited first. A household was defined in terms of persons who were co-resident and shared common cooking arrangements, and were able to recognise one person as the head of household [ 18 ].

From Research to Road Map: Learning from the Arms for Development Initiative in Sierra Leone

Enumerators proceeded to the next household, until the total number of households to be sampled from that village was completed. The survey tool [see Additional file 1 ] was developed in consultation with the Bonthe DHMT and with assistance from maternal and child health experts within the World Vision Partnership.

A total of 30 community health workers CHWs were selected as enumerators to participate in the household survey training, hosted by staff from neighbouring health centres and the DHMT. As part of the survey training enumerators were taught how to administer the questionnaire, record responses from participants, verify patient health cards, interpret the mid-upper arm circumference MUAC tapes, and weigh and measure children. To minimise the risk of response bias, answers were verified through child and maternal health cards i. The presence of a mosquito net and latrine was verified by the enumerator, as was the cleanliness of the latrine.

Piloting of the questionnaire took place in villages not included as part of the final sampling frame. Where appropriate, questions were phrased in binomial i. Though the questionnaire was printed in English, training was conducted in a mixture of Krio and Mende and CHWs were instructed to conduct the interview in whichever language they felt best suited the household. A sample of households across all villages in the riverine, and households across of the villages on the mainland were ultimately represented in the study sample, for a total of households.

To maximise all data available, missing data was handled using pairwise deletion. Rank variables were compared across the two areas using the Mann-Whitney test. Maternal health, child health and sanitation indicators in Bonthe District were compared across two geographically different areas; the riverine and the mainland.

In the riverine, households were visited and surveys were collected, amounting to a response rate of Non-responders include those that did not meet the criteria for inclusion as well as those that refused to participate. During post-hoc analysis however, gender was not found to be a confounding factor across the specific child variables measured and therefore the groups were still considered comparable. Of the pregnant women interviewed, Almost half Moreover, there were no significant differences between the number of women who had reportedly slept under an ITN the night preceding the survey; women who correctly identified two methods of prevention of mother to child transmission of HIV PMTCT ; and the number of women who had been tested for HIV during their pregnancy.

More than half Likewise, While no changes were observed in the riverine, delivery in the presence of a SBA and within a health centre appears to have increased, and the use of TBAs decreased, on the mainland among deliveries occurring after the introduction of the FHCI. There was no difference between the number of children in possession of a birth certificate across the two areas. We found no differences in coverage of deworming among children aged 12—59 months or vitamin A supplementation among children aged 6—59 months across the two areas.

Only When disaggregated by type of immunisation, significant differences were found across the vaccine schedule, including a difference of 4. Only measles had no significant difference in vaccination coverage across the two areas. There was a statistically significant difference of In the riverine, However, there was a significant difference Nearly a third Significant differences Of those households with access to a latrine, Differences in health indicators across distinct geographic areas have been noted in other contexts [ 19 ] and recent studies have called for additional research exploring regional variability in the delivery of maternal and child health services in sub-Saharan Africa [ 20 ].

In line with this, our study identifies discrepancies in maternal and child health indicators across two separate contexts, the mainland and the riverine, both served by the same district health management team. Results suggest no significant differences in the demographic make-up of both groups, allowing us to compare them for the purpose of the study. Specifically, we found no differences in age, education and marital status, all of which are well recognised as important determinants of women accessing maternal health services [ 21 — 24 ].

There were however, four main differences across maternal and child health indicators between the riverine and mainland found in this study. In terms of reproductive health services, women on the mainland reported a higher use of family planning traditional or modern , compared to women in the riverine. There were also key differences in place of delivery between the riverine and the mainland, with the mainland reporting more frequent facility based deliveries and a greater use of skilled birth attendants.

More importantly, further stratification suggests that the differences for children born in a health centre and in the presence of a SBA or TBA only existed for children born after the introduction of the FHCI. However, in the riverine there was no difference seen between pre- and post-FCHI. Thirdly, child immunisation rates, with the exception of measles, were higher on the mainland. While differences existed whether children had been born prior to the initiation of the FHCI, the differences were less pronounced for children born after the introduction of the FHCI.

Taken together, our results point to the need for more resources to be put into reproductive, maternal, and child health services in the riverine. Specifically, the Bonthe DHMT should consider directing more resources towards increasing access to family planning, delivery services, and skilled birth attendants. More immunisation efforts are also needed in the riverine and additional investment is necessary to improve water and sanitation services.

The following sections draw from the extant literature to explore the potential reasons for these observed differences and make suggestions for how these could be addressed. A recent systematic review of drivers and deterrents of accessing a health centre for reproductive and maternal health in sub-Saharan Africa identified maternal education, parity, household socioeconomic status, rural or urban dwelling, distance to a health facility and number of ANC visits as the factors most consistently associated with having a facility based delivery [ 20 ].

Similarly, attitudinal resistance, awareness of services, societal and cultural pressures, socioeconomic barriers, availability of transport, access to appropriate services, and perceived quality of care are commonly cited barriers to reproductive health services [ 26 — 33 ]. The last three are characteristic of health system failures and of particular relevance to a district health management team.

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Among other environmental factors, accessibility and availability of transport are commonly noted throughout the literature to impact on health service [ 34 ]. In this study, the difficult terrain characteristic of the riverine may partly explain why women in the riverine are more likely to give birth at home rather than in a health centre.

The topography of the riverine requires that one navigate a complex system of rivers, lagoons and estuaries both on foot and by boat. With previous studies linking long travel times to increases in child mortality [ 35 — 37 ], it is important that pregnant women access a health centre at the time of delivery.

As a recommendation, the DHMT might consider the use of maternity waiting homes, or a facility within reach of a health centre that provides emergency obstetric care [ 38 ]. Maternal waiting homes have been employed in other low-income contexts, including neighbouring Liberia, where they were found to be an effective strategy for increasing the use of skilled birth attendants and improving maternal and neonatal health [ 39 ].

As, if not more important, than ensuring a safe and clean environment for delivery however, is the availability of a skilled health worker. In addition to restricting access to care, difficult geographical conditions can also result in poor living and working conditions for health staff. Studies have highlighted the lowered performance of health workers on remote islands such as those represented in the riverine [ 40 ] and other remote peripheral health units in Sierra Leone have also shown significant inefficiencies [ 41 ]. Poor working conditions in turn, are associated with poor performance, increases in attrition rates, and difficulties recruiting health workers, as individuals prefer not to be posted to remote and difficult locations with poor infrastructure and far away from their family [ 42 — 44 ].

The terrain and remoteness of Bonthe District make it an unpopular location for health workers, with the riverine being particularly understaffed. The DHMT may want to consider additional incentives as a means of enticing health workers to the riverine. Salary top-ups and other non-financial incentives such as providing free housing and further education opportunities were found to impact on the willingness of nurses to work in remote areas of Tanzania [ 45 ]. In addition, the DHMT may want to select health workers who are more intrinsically motivated [ 46 ] and who originate from very remote areas, as they have been found to express a greater willingness to take up a remote position [ 45 ].

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To maintain the equitable delivery of MCH services, it is imperative that less resourced areas have in place strategies to maintain a satisfied health workforce. Widely recognised as effective preventative practices, child immunisation and appropriate water and sanitation are important determinants of maternal and child health [ 47 , 48 ]. In contexts with scare human resources for health, enlisting the help of alternative cadres of health worker, such as the community health workers CHWs , is recommended for the effective delivery of preventative maternal and child health care interventions [ 49 ].

CHWs are considerably less expensive to train, are selected by the very communities they serve, and with adequate training, can help address many of the cultural barriers often associated with delayed or inconsistent access to health care services [ 50 , 51 ]. The use of CHWs may be particularly appropriate for the riverine, given its remoteness and difficult topography. Affordability is also an important factor when considering the equitable access to transport and health services.

Though the FHCI theoretically removed user fees, studies report that women have continued to pay for services since the initiation of the scheme [ 52 ]. Unfortunately, these findings are not uncommon in free health care initiatives [ 53 , 54 ], with patients continuing to pay out-of-pocket for transport, medical supplies, and for informal payments requested by health centre staff.

These expenses are likely higher in areas such as the riverine, where there are longer distances to travel to the health facility, resources are scarcer or more difficult to obtain, and where the working conditions for health staff are considerably worse. A more recent study conducted in Sierra Leone on the impact of removal of user fees showed that more educated women were more likely to benefit from their removal, with no impact on service utilisation across wealth quartiles [ 55 ].

As McKinnon et al. Barriers that impact on socioeconomic inequalities, and access to quality service need to be addressed and included within national plans if Sierra Leone is to implement their FHCI equitably and efficiently amongst its population. It is worth noting that along with the introduction of the FHCI, Sierra Leone also made illegal the practice of deliveries being assisted by a traditional birth attendant TBA [ 56 ]. The decision to give birth in the presence of a TBA is largely influenced by cultural and societal norms, with individuals reporting a more personal relationship, better quality care, and greater trust in TBAs.

TBAs are also considered to be more affordable, as they are amenable to being paid in-kind or by instalments [ 58 ]. These factors may all contribute to our observation of greater TBA use and a greater prevalence of women giving birth at home in the riverine. In the absence of a greater number of trained health providers posted to the riverine, TBAs remain an important resource for the transmission of health messaging and to increase service utilisation.

For example, TBAs are an important resource to encourage pregnant women to come to the health centre to attend antenatal services and when engaged appropriately, and like community health workers [ 49 ], can act as an important bridge between communities and more formal health systems [ 39 ]. Consideration should be given for how to best engage TBAs in Bonthe District, as an important strategy to achieve a more equitable maternal health care service.

While the Government of Sierra Leone GoSL currently provides health resources to the Bonthe DHMT through both the Bonthe Municipal Council located in the riverine , and Bonthe District Council located on the mainland , resources are allocated on the basis of population with little consideration for typography, difficulty of access, and the demographic profiles of potential health care users.

The results of this study indicate that the riverine may be disproportionately disadvantages by a lack of resources.

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Contingencies for areas of greater need should be developed and implemented, which includes increased availability of skilled health workers, more focused immunisation campaigns, and greater resources to address the lack of access to water and sanitation. In other words, initiating a free MCH programme alone is not enough to reduce disparities within populations and resources in Bonthe District should be allocated to specific health centres on the basis of need, rather than on the basis population.

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Early involvement of stakeholders is particularly important in the early stages of MCH programmes as they can provide important suggestions for programme re-alignment, and how to meet end-user expectations [ 59 ]. Helping programmes better plan for service delivery is important to ensure access to care for more vulnerable populations and to deliver equitable health services.

Additional research into the reasons for the observed discrepancies will be important to further inform the implementation of health activities and the distribution of resources going forward.

Data from this study was collected prior to the Ebola outbreak that afflicted Sierra Leone and its neighbouring countries of Guinea and Liberia. The recent outbreak resulted in over deaths in Sierra Leone alone [ 60 ] and has left an already under-resourced and overstretched health system in a severe crisis. With 6. The tragic loss of health staff has the potential to result in an estimated additional women dying during pregnancy and childbirth per year across Sierra Leone, Guinea and Liberia, reminiscent of levels during the civil conflict [ 62 ].

Findings during the outbreak have indicated a decrease in RMCH service utilization [ 63 ], with evidence that Ebola has disproportionately affected women and children [ 64 ]. In the aftermath of Ebola, it is predicted that its devastating consequences will again most be felt by women and children [ 61 ].

It is therefore not unreasonable to assume that the discrepancies observed in this study will be exacerbated as a result of the recent Ebola outbreak, causing a further decay of the health care system and an even greater shortage of health workers. The challenge for Sierra Leone will be to rebuild and strengthen its health system in an efficient and equitable manner. As these findings show, considering existing discrepancies and contextual conditions, over and above populations numbers, are essential to ensure equitable — not just equal - distribution of maternal and child health resources.

This study is not without its share of limitations. Notably, sampling errors may have occurred during the development of the sampling frame, impacted by the non-availability of community maps. Similarly, only households where someone was present during the day were sampled, excluding houses where people were away working or caring for their farms. In addition, a pocketing effect may have been introduced due to the random number generators for first house selection. This pocketing effect could influence certain indicators, such as immunisation rates.

Bias may also have been introduced during the data collection process. In addition, this survey was conducted during the dry season, which may impact on the reported incidence of certain diseases, notably diarrhoea, which is more prevalent during the rainy season. As we move towards progressing the Sustainable Development Goals SDGs , the challenge remains to identify specific geographical inequities in service requirements and establish context specific strategies to increase access to maternal and child health care for less accessible populations, for whom health resources are often offered at a premium.

Though Sierra Leone has seen a significant increase in health-care use since , the capacity of the health system to respond to this increased demand for services in the wake of Ebola remains uncertain. As a result, the most vulnerable populations of children and women are not equitably benefiting from national efforts such as the FHCI to improve maternal and child health.

This paper provides one example of how two distinct contexts covered by the same health district management team can demonstrate very different indicators for maternal and child health.

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More context-specific approaches are necessary in Bonthe District in order to address the inequities in maternal and child health indicators highlighted in this study. Similarly, if the government of Sierra Leone is going to deliver on their promise to free health care for pregnant women and children greater attention must be paid to the existing service delivery gaps within each District.

At a glance: Sierra Leone. Safe delivery: reducing maternal mortality in Sierra Leone and Burundi. Moszynski P. Br Med J. Maternal mortality: to Geneva: WHO Press; Go SL. Freetown: Statistics Sierra Leone; Donnelly J. How did Sierra Leone provide free health care? Readhead A. Sierra Leone: keeping children alive, in Aljazeera. Doha: Aljazeera; Diaz T et al.