April 2017

1. Review of Sierra Leone National health sector strategic plan (NHSSP) 2010-2015 and process for development of NHSSP 2017-2021 April 2017

2. Overview NHSSP 2015-2020 review (finalized February 2016) Rationale Methodology Limitations Achievements, challenges and recommendations by NHSSP pillar Proposed process for development of NHSSP 2017-2021 Rationale Objective and scope Process and budget Timeline and key milestones

3. Review of National Health Sector Strategic Plan 2010-2015 (finalized February 2016)

4. Rationale for review of 2010-2015 NHSSP Document achievements and best practices Identify reasons for inadequate implementation, gaps and causes of system vulnerabilities Propose strategic recommendations for development of next NHSSP 2017-2021

5. Methodology Requested by MOHS, technical support by WHO Independent review team of five health experts – three international and two local Recommend interventions to address gaps in the health Desk review of relevant documents Key informant interviews with MOHS directorates, programmes, development partners and other ministries Field visits to two districts Port Loko and Kambia

6. Limitations of review Two weeks (mid-December 2015) limited time for such a broad sector review Some key stakeholders not available Inadequate evidence on current system vulnerabilities Lack of systematic performance documentation over the last three years Inadequate information from routine information systems

7. Service delivery • Achievements • Improved health outcomes on several key indicators (2008-13) • Triage systems and IPC widely implemented (during Ebola) • Revised Basic Package of Essential Health Services (BPEHS) and several key guidelines updated • Geo-mapping/updated policy on community health workers • Improved awareness of health worker safety • Attempts to improve ambulance services • Challenges • BPEHS not prioritized or costed • Little coordination among vertical programmes • Role of CHWs vis-à-vis facility staff unclear • Low consultation rate for outpatient departments pre--EVD (no recent data available) • Expansion of facilities, but maintenance/performance uncertain • Poor environmental health/ waste disposal outcomes • Irregular supervision to all PHUs • Key recommendations • Develop a prioritized/ costed roadmap for BPEHS, forming the basis for the next NHSSP • Prioritize and implement environmental health and waste disposal interventions • Consider better coordination among vertical programmes • Develop strategies to reduce demand side barriers • Reinforce community mobilization and outreach • Ensure new CHW policy, realistically costed and integrated with overall system

8. Human resources for health • Achievements • HRH policy and strategic plan (2011-2015) developed • Performance-based funding (PBF) system/incentives established • Training centres with standard curriculum for MCH Aides established • Human Resource Information System (HRIS) established • Capable staff in non-clinical positions (DHMTs, central level) • Salaries increased, with relevant in-service training sessions • Challenges • No clear costing of HRH • Health facilities understaffed with high urban/rural disparities • High percentage of unpaid workers • Inadequate capacity at training institutions • Inadequate coordination with other ministries • Fragmented CHW system • Staffing in facilities not conformed to BPEHS staffing norms • PBF/incentives is not regular • HR management centralized • Key recommendations • Develop, clear, costed long-term HRH development plan with budget • Strengthen institutions for implementation of HRH plan as well as HRH absorption • Devolve human resources management • Restructure remote allowance and PBF • Establish and implement coordinate training and career progression system • Strengthen HRIS and integrated related systems (payroll, attendance, etc.)

9. Medical products and technologies • Achievements • Legal/policy frameworks being established • Free Healthcare Initiative providing better access to some drugs • Electronic management information system for drugs initiated • Institutions for supply chain/drugs established (e.g., Pharmacy Board with quality control lab) • Reform of National Pharmaceutical Procurement Unit initiated • Pharmacy staff in DHTMs • Challenges • Existing legal/policy frameworks not well enforced • Supply chain vertical/uncoordinated • Push system in place • Heavy donor dependency • Inadequate cost recovery system • LMIS not fully functional • Inadequate storage infrastructure • Poor rational use of drugs • Drug therapeutic committees not functional • Poor medical equipment maintenance/replacement plan • Key recommendations • Develop and enforce key legal/policy frameworks • Harmonize vertical supply chain systems • Establish revolving fund for drugs and consumable at central, DHMT and facility levels • Fully implement e-LMIS under Government ownership • Shift from push to pull to match demand with supply • Develop enforce guidelines on rational drug use and revive drug therapeutic committees

10. Health information system and M&E • Achievements • Results and accountability framework developed • Data managers at DHMTs with staff equipped with relevant tools for data management • DHIS2 established • Efforts to improve data quality for specific programmes • Integrated Disease Surveillance and Response system strengthened • Efforts to use data for planning/reviews at district level • Challenges • No reliable source of routine information • Capacity of reporting routine data from PHUs inadequate • Existing information systems not integrated • Weak data infrastructure • Vital statistics are not complete • Poor data use and feedback from central to district and facility levels • Inadequate training of M&E staff • IDSR, although strengthened, not yet integrated with other systems • Key recommendations • Strengthen MOHS Directorate of Policy, Planning & Information to conduct regular data analysis and quality checks and improve data management across programmes/levels • Establish accountability mechanisms for data quality, using PBF and other mechanisms • Establish one-stop centre for health information from health facilities using DHIS-2 platform • Institute regular data dissemination and use (bulletins, review meetings, performance reports) • Facilitate integration of IDSR with DHIS-2

11. Health care financing • Achievements • Increase in share of total government spending for health (NHA 2013) • Free Healthcare Initiative (FHI) with PBF shown several key gains: increased uptake of services in target population; motivated health workforce; BEmOCand CEmOC facilities have been established • 33% of total health spending on reproductive health and family planning • Challenges • Underfinancing of health sector leading to catastrophic OOPs • High dependence on external resources • Many facilities run by volunteers • No financing policy and strategy • DPPI Healthcare Financing unit (HCF) understaffed/underutilised • No visible efforts to diversify domestic resources • Inadequate capacity to advocate for and use resources • Questions on sustainability of FHI • Key recommendations • Develop health financing strategy and implementation plan • Restructure and strengthen the HCF unit • Strengthen MOHS activities linked to resource mobilization, costing, financing and value for money • Identify mechanisms to reduce OOPs • Rethink and strengthen the cost recovery system

12. Leadership, governance and planning • Achievements • Increasing political will to prioritize health sector, including initiatives from the State House • Development of flagship programmes and recovery plan • Existence of key coordination structures • Service Level Agreements initiated to streamline implementing partners • Efforts to improve relationships between DHMTs and district councils within framework of partial devolution • Challenges • Inadequate ownership/commitment to implementation of NHSSP • Weak policy dialogue and mutual accountability • Existence of many overlapping and competing plans and priorities • Inadequate effort to strengthen MOHS systems (too project focused) • Weak review/monitoring mechanism • Incomplete decentralization • Poor credibility of budgeting process • Key recommendations • Complement the functional devolution with expenditure decentralization (accountability at district levels) • Improve the budgeting and disbursement process (conservative budget ceiling) • Improve ownership and feasibility of plans • Develop and implement HSS capacity development plan • Strengthen the leadership, planning and management of partner coordination

13. Proposed process for development of National Health Sector Strategic Plan 2017-2021

14. Rationale • Incorporate recommendations from the NHSSP 2010-2015 review (some already being implemented) • Build on key elements of the Health Sector Recovery Plan 2015-2020 and Basic Package of Essential Health Services 2015-2020 and sub-sector/programme plans • Provide an overarching framework for the sector in the medium-term National Health Sector Strategic Plan 2017-2021 Review recommendations Consultative process Mental health IDSR RMNCAH Nutrition cMYP TB Labs HIS HIV Malaria IPC HRH Sub-sector/ programme plans* Health Sector Recovery Plan 2015-2020 (including 6-9 months plan and President’s Recovery Priorities) Basic Package of Essential Health Services 2015-2020 *Indicative list of plans – not complete

15. Objective and scope Develop a costed, five-year strategic plan for the health sector aimed at improving the health and well-being of all Sierra Leoneans Provide direction for improving overall delivery system Assessment of health situation in Sierra Leone, including financing status Prioritized strategic interventions Cost of implementing the NHSSP Implementation plan M&E framework

16. Process Inclusive, participatory process covering a four-month period commencing in January 2017, using existing mechanisms and structures Under leadership of the DPPI, with technical support from WHO, constitute core working groupcomposed of MOHS and other partners Comprehensive review of existing/upcoming sub-sector and programmatic strategies to inform key priority areas/indicators MOHS- and government-level consultations, including with other sectors: regular updates to HSCC, HSSG, CMO management meetings, technical working groups, meetings with other sectors District- and community-level consultations: engagement during district meetings/visits, additional consultations at district and community levels Partner, civil society and private sector consultations: regular update at HDP, NGO Forum, meetings with private sector Consultation/validation workshops and other ad hoc meetings

17. Budget

18. Timeline and key milestones Continue consultations Identify/prioritize key strategic interventions Initiate costing of plan Initiate M&E framework  April June May Finalize ToRs Constitute working group Initiate consultations Initiate analysis of sub- sector/ progamme plans • Finalize costing • Finalize M&E framework • Final consultations • Validate plan • Final NHSSP 2017-2021

19. Thank you