By Alhassan Fouard Kanu, UK.
Sierra Leone is renowned as a country where children and women (due to childbirth) are dying more than any other country in the world. This has, in the past, shamefully contributed to our bottom position in the Human Development Index.
Anecdotal evidence has it that, most of the deaths in our vulnerable women and children are as a result of physical and economic barriers to quality healthcare services. In April 2010, the country’s political elites, championed by His Excellency, Dr Ernest Bai Koroma offered free health services to the vulnerable groups of women (pregnant and lactating mothers) and children below the age of five years; with support from DFID, World Bank and other development partners.
This move has, albeit few challenges saved the lives of many of our children and women from needless deaths. The Free Healthcare initiative (FHCI) has also opened opportunities for the strengthening of our health system; and this means a golden era in the Ministry of Health and Sanitation (MOHS).
The Emergency Obstetric and Neonatal Care (EmONC)
There is currently no silver bullet strategy in the fight to reduce maternal and child mortalities; considering the myriad of challenges and the interconnection of obstacles in accessing and the availability of quality health care. What is globally employed though, is the Emergency Obstetric and Neonatal Care (EmONC); this advocates for the provision of appropriate quality services gears towards saving the lives of the poor women (whilst pregnant and/or during labour) and children (especially the newborn) at all levels in the healthcare delivery system.
There is currently no facility in our country, apart from privates, that meets the required MOHS standard to be labelled an “EmONC unit”. It is the vision of the MOHS to ensure that, all Community Health Centres (CHC) in the country are equipped to be able to provide Basic Emergency Obstetrics and Neonatal Care (BEmONC) and all hospitals are equipped to provide Comprehensive Emergency Obstetrics and Neonatal Care (CEmONC). Accomplishing this feat is not instantaneous, considering the resources- both financial and human- needed in meeting the set requirements. In the quest to follow suit global effort in tackling maternal and child morbidity and mortality, the MOHS and the thirteen (13) District Health Management Teams (DHMT) selected 65 CHCs (5 per district) and thirteen (13) hospitals (1 per district) to serve as BEmONC and CEmONC respectively in the next few years.
Facility Improvement Team (FIT)
Even though the selected facilities are now referred to as EmONC units, it is misnomer as none is nearer to becoming qualified; especially the CHCs/BEmONC.
In a bid to promote a conducive environment and our facilities manned by the right personnel among other requirements in line with global standards, the MOHS identified seven requirements which became known as the ENABLERS, to be in place for the functioning of EmONC units and these are:
Water and Sanitation- this calls for a 24 hour availability of safe drinking water in the facility; carried through pipes in the labour room; and the availability of waste disposal using either incinerator or burial pit among others.
Electricity- facilities require 24 hour availability (when needed) of power- especially in the labour room- from sources including central power, solar and generator. A back up source is also needed to fulfil this requirement.
Referrals- this requirement is looking at two areas: transportation and communication. On transportation, there must be a 24 hour ambulance service available at the facility. On communication, there must be the possibility of 24 hour communication using cellular phones or VHF to call for ambulance service.
Equipment for special procedures- important instruments are required by facilities to be able to respond to EmONC needs and ALL of them must be present at the facility. In addition, staff at such facility must be competent in performing life-saving EmONC procedures.
Blood storage and Laboratory services- there must be a functioning laboratory (with a trained lab assistant) in EmONC facilities that can do haematology, microscopy and biochemistry.
Staffing-this requirement calls for the placement of the right and competent staff in EmONC facilities.
Drugs and Supplies-the requirement calls for the non-stock outs of ALL 16 tracer drugs Plus IV/IM antibiotics, oxytoxics and anticonvulsants
Sierra Leone is counting on its political commitment to improving the health of women and children and which would, a long way facilitate the success of the “turn-around” of our poor health system. His Excellency has signed a contract in 2010 with the MOHS to measure indicators related to the reduction of maternal and child deaths and this became known as the Presidential Performance Contract (PPC). Considering the challenges involved in getting all the 5 CHCs and 1 hospital per district to become EmONC compliant within a year, the contract instead toned down the number to 2 CHCs and 1 hospital to become certified as BEmONC and CEmONC respectively in every district. One of the indicators in the contract is the enabler tracking of the targeted facilities (26 CHCs and 13 hospitals) and which must fulfil all the ENABLERS requirements by December 2011.
The MOHS, through the RCH Directorate has set up a separate team that will be responsible for tracking progress of these ENABLERS quarterly. These teams became known as the Facility Improvement Team (FIT). The overall objective of the FIT teams is to assist the districts in monitoring the implementation of all ENABLERS to become EmONC certified and assuring that quality service delivery is provided.
The first FIT assessment was done in November 2010. In 2011, the second quarter FIT assessment completed last week and reports of these assessments are shared with state house.
Performance Based Financing (PBF)
The initiation of the FHC scheme is meant to accelerate the reduction of maternal and child mortality rates in the country. The scheme targeted the reduction or removal of financial barriers to accessing quality healthcare delivery services for our vulnerable groups of women and children. Performance-Based Financing (PBF) is one of the strategies for the implementation of the FHC scheme by ensuring clear link between financial resources and the MDG’s outcomes. The performance-based financing mechanism funds healthcare service providers according to the outputs (healthcare service provision) or outcomes (health status of the target population) that they provide. The general objective of the PBF system is to help change the behaviour of health providers at facility level for them to deliver more quality services and to increase their productivity under the free health care policy.
There are currently six (6) interventions for which service providers are paid for and such payment will depend not just on the quantity of services delivered, but also on their quality:
Women of reproductive age using modern family planning methods for protection against unwanted pregnancy and to achieve desired birth spacing (Le6,000 per woman served)
Pregnant women receive four appropriate antenatal consultations for protection against pregnancy risks (Le6000 per pregnant woman)
Deliveries are conducted under safe conditions: by qualified staff in an equipped health facility (Le10,000 per delivery)
Women receive three postnatal consultations for protection against post-delivery risks (Le6,000 per woman)
Children receive full and timely course of immunizations against communicable diseases (Le6,000 per child)
Outpatient visits for children under five years old (Le300 for each consultation)
It is expected that the PBF will increase service utilization as well as improving the quality of service delivery at primary health care facility. A well designed PBF system will, in no doubt motivates staff to deliver services in the right places and enables them to access the resources needed to do this.
One of the agency in the lead for such laudable work in our country is OPTIONS CONSULTANCY SERVICES UK LTD. Options Consultancy Services is contracted by DFID to manage a programme of technical assistance to the MOHS. The programme is aimed at supporting MOHS to improve the financing, management and delivery of sustainable and replicable pro-poor health services to ensure the achievement of the national Reproductive and Child Health (RCH) Strategic Plan within the context of the National Health Sector Strategic Plan.
I would want to implore ALL to support His Excellency’s inspiration and vision in reducing the unacceptably high maternal and infant morbidity and mortality rates. The mechanisms in place will not only save the lives of the targeted population but will also strengthen our health system for the benefit of every citizen and hence, the socio-economic development of Sierra Leone.