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«EYE HEALTH SYSTEMS ASSESSMENT (EHSA): SIERRA LEONE COUNTRY REPORT March 2013 Contents Acronyms Executive Summary 1. Introduction 2. Methodology of ...»

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March 2013



Executive Summary

1. Introduction

2. Methodology of the Eye Health System Assessment

3. Sierra Leone: health system overview

4. Overview of the eye health system







5. Summary of Findings

Annex A: Map of Sierra Leone: Provinces and Districts

Annex B: Eye Health System Assessment Team

Annex C: Sierra Leone EHSA Schedule: 08-18 January 2013

Annex D: List of Interviews conducted and sites visited

Annex E: List of documents consulted


ii This publication was produced by Amy Potter (ICEH), Matthew Vandy (MoHS), Nancy Smart (Sightsavers) and Karl Blanchet (ICEH).

We thank all the following people who contributed to the assessment and the final publication: Mr. Edward Sandy (MoHS), Mr. Ernest Challey (MoHS), Mr. Sheku Koroma (MoHS), Mrs. Emerica King (Sightsavers), Mr.

Alpha Bangura (Sightsavers).

Eye Health System Assessment (EHSA) is an ICEH project funded by Sightsavers for strengthening eye health systems worldwide. By supporting countries to improve their health financing, governance, operations, and institutional capacities, EHSA helps eliminate barriers to the delivery and use of priority eye care.

Recommended Citation: Potter, A.L., Vandy, M., Smart, N. Blanchet, K.l., 2013, Eye Health Systems Assessment (EHSA): Sierra Leone Country Report, Ministry of Health and Sanitation, International Centre for Eye Health, Sightsavers.

All EHSA-related documents and guidelines can be found online on:


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APOC African Programme for Onchocerciasis Control BEHL Baptist Eye Hospital, Lunsar (Northern Province) BPEHS Basic Package of Essential Health Services CBM Christian Blind Mission CBR Community Based Rehabilitation CDD Community Directed Distributer CDHP Comprehensive District Health Plan CHC Community Health Centre CHN Community Health Nurse CHO Community Health Officer CHP Community Health Post CMH Catholic Mission Hospital, Serabu (Southern Province) CMO Chief Medical Officer (C)ON Certificate or Community Ophthalmic Nurse (with an SEHRN background) CSC Cataract Surgical Coverage CSO Civil Society Organisation CSR Cataract Surgical Rate DDMS Directorate of Drugs and Medical Supplies DHIS District Health Information System DHMT District Health Management Team DMO District Medical Officer DPO Disabled People Organisations (D)ON Diploma Ophthalmic Nurse (with a SRN background) EC European Commission ENT Ear Nose & Throat EPECP Eastern Province Eye Care Programme EPI Extended Programme of Immunisation FBO Faith-based Organisations FHCI Free Health Care Initiative HFAC-SL Health for All Coalition, Sierra Leone HR Human Resources HReH Human Resources for Eye Health HRH Human Resources for Health HRIS Human Resource Information System IOL Intra-Ocular Lens iv JPWF Joint Programme of Work and Funding, Ministry of Health and Sanitation MCH Maternal and Child Health MCHP Maternal and Child Health Posts MOHS Ministry of Health and Sanitation MOSW Ministry of Social Welfare, Gender & Children's Affairs MOU Memorandum of Understanding MVI moderate visual impairment NECP National Eye Care Programme (the former name of the NEHP) NEHP National Eye Health Programme NEML National Essential Medicines List NHSSP National Health Sector Strategic Plan, Ministry of Health and Sanitation NPPU National Pharmaceutical Procurement Unit NTD Neglected Tropical Diseases OCHO Ophthalmic Community Health Officer ON Ophthalmic Nurse OPD Outpatients Department OPP Out of Pocket Payment PBF Performance Based Financing PEC Primary Eye Care PHC Primary Health Care PHU Peripheral Health Unit RAAB Rapid Assessment of Avoidable Blindness SCB Standard Chartered Bank SECHN State Enrolled Community Health Nurse (eligible to train as a Community Ophthalmic Nurse) SRN State Registered Nurse (eligible to train as a Diploma Ophthalmic Nurse) SLAB Sierra Leone Association of the Blind SLUDI Sierra Leone Union on Disability Issues SPECP Southern Province Eye Care Programme SVI severe visual impairment UMC United Methodist Church, Kissy (Western Area) WAECP Western Area Eye Care Programme WHO World Health Organisation WTE Whole time equivalent (of a member of staff)

vExecutive Summary

Overview of the eye health system Strengths

• The Ministry of Health and Sanitation (MOHS) is engaged and eye care is integrated into government policies.

• During the last five years, service coverage and quality of eye care services has increased.

• Faith-based Organisations (FBOs) make services available in areas where there are no government facilities, often provide free cataract surgery, and undertake two thirds of the cataract surgeries in Sierra Leone.

• There are plans to train significant numbers of new eye care staff by 2016.


• The public budget for eye care is inadequate.

• Inequitable distribution of government eye facilities and staff, particularly in the north.

• The integration of eye care services into general hospital administration varies between facilities.

• Low Cataract Surgical Rates (CSR).

• Limited provision of refraction and low vision services.

• Weak monitoring systems for patient feedback, eye care activity or outcomes.

Governance of the eye health system Strengths

• Eye care is included in core health services in Sierra Leone, and health regulations and policies are applied to eye care.

• In areas where there are government-managed eye care staff and facilities, they tend to be well linked to traditional chiefs, the District Health Management Team (DHMT) and any local Schools for the Blind.


• The national VISION 2020 Committee has not met regularly in the past, to the detriment of national coordination.

• The government is not responsive to the eye health needs of the population in the north.

• Disabled People’s Organisations (DPOs) and other Civil Society Organisations (CSOs) have limited opportunity to be involved in the planning of eye health services.

• Limited feedback or complaint mechanisms to enable service users to have a voice.

Eye health financing Strengths

• Introduction of the Free Health Care Initiative (FHCI) in 2010 means eye care services (where available) are free to all under fives, pregnant or lactating women.

• National Eye Health Programme (NEHP) Manager is involved in MOHS budget negotiations.

• FBOs are often able to provide free surgery, which positively impacts on cataract surgical rates.


• MOHS budget for eye care is inadequate, and mainly covers administration rather than service delivery.

• Whilst FHCI has increased access for the groups it covers, it has limited the MOHS funds available for other services or population groups.

• There are no budgets for eye care at district level which limits integration of eye care services.

• Government eye units are often perceived as separate from the rest of the hospital, as funding for drugs and consumables comes directly from NEHP or from Sightsavers.

Eye health service delivery Strengths

• There is a comprehensive network of Peripheral Health Units (PHUs) covering Sierra Leone, staffed with health care workers who have some training in recognising and treating basic eye conditions.

• Eye care services are included in the Basic Package of Essential Health Services (BPEHS) for Sierra Leone.

• The number of people accessing eye care services has increased, through a combination of increased awareness, increased service provision, and reduced financial barriers through the free healthcare initiative.


• Inequitable distribution and access to eye health services. This affects the Northern Province particularly, and remote areas of other Provinces.

• Although the network of PHUs with staff trained in basic eye care theoretically provides a good referral system, in practice, the referral rate is poor.

• The CSR is too low to deal with the incidence and prevalence of blindness due to cataract.

• Lack of clear supervision system defining responsibilities at each level for eye health.

Human resources for eye health Strengths

• General health care staff working in primary care are trained in basics of eye care.

• Key eye care staff (Certificate and Diploma Ophthalmic Nurses (CON/DON), and Ophthalmic Community Health Officers (OCHO)) can now be trained in country due to available funds and training courses.

• Consortium European Commission (EC)/ Standard Chartered Bank (SCB) funding is available to address some of the key gaps in eye care staff.


• Significant gaps in numbers of eye care staff, and inequitable distribution compared to the population distribution, particularly in the Northern Province and outside urban areas.

• Nurses and doctors are not attracted to specialise in ophthalmology.

• The pool of staff eligible to train as Cataract Surgeons is limited, and current delays in training Ophthalmic Nurses impacts on the throughput required to train Cataract Surgeons in the future.

Medicines, products and equipment for eye health Strengths

• Health regulations are applied to eye care in the same way as to other health services.

• The National Essential Medicines List (NEML) and the BPEHS drug list include key eye care drugs.

• Separate funding and procurement mechanisms in government-run Sightsavers-funded eye clinics helps to maintain the supply of eye drugs and consumables.


• Some key eye drugs are missing from the NEML.

• FBOs are not included in FHCI so are not reimbursed for drug spend on children or pregnant/lactating women.

• Specialised eye care drugs are not always available in government hospitals in the Northern Province that are not supported by Sightsavers.

Health information systems for eye health Strengths

• A standardised Health Information System is used by all PHUs and government hospitals; the system has the capability to add more eye care-specific indicators in the future.

• Activity reports are generally sent from eye health staff within hospitals to the DHMT, hospital management and the NEHP.


• Reporting on the number of eye infections seen in PHUs does not provide enough information to make decisions at the local, district or national level.

• There is lack of sufficient data to effectively monitor services, or assess whether particular groups are under-represented.

• Facilities often do not receive any feedback from the NEHP about their performance.


• Sightsavers for funding the development of the EHSA approach

• Sierra Leone National Eye Health Programme for leading and hosting the assessment

• Sightsavers Sierra Leone Country Office for providing vehicles and oversight to the assessment

• All those who agreed to participate in interviews

1. Introduction

Governments across the world face difficult challenges in meeting their populations’ health needs, and this is exspecially the case in Low and Middle Income Countries (LMIC) which, whilst facing economic and human resource constraints, need to respond to communicable health threats such as HIV and malaria, as well as an increasing burdens of Non-Communicable Diseases (NCDs).

There is an increasing acknowledgment that a “health system approach” is needed to address these challenges. Instead of targeting a single area or disease, a country’s health system needs to be strengthened as a whole. USAID have therefore developed the Health Systems Assessment (HSA) Approach1-2, for rapidly

assessing strengths and weaknesses of a country’s health system. The impact has been very positive:

between 2007 and 2012 more than 20 countries have undertaken assessments.3 Over the last few years, increasing efforts have been invested in exploring the relationship between the eye health system and the general health system. Around 80% of visual impairment is preventable or curable through effective eye care services. General consensus is emerging in the international eye care community that the effectiveness of eye care interventions can only be improved through better understanding how health systems function. A consortium of eye care experts and health experts, coordinated by the International Centre for Eye Health (ICEH) at the London School of Hygiene and Tropical Medicine (LSHTM), have therefore developed the Eye Health Assessment approach (EHSA),4 funded by Sightsavers.

The objectives of the EHSA are to:

• Enable national and international eye care actors to regularly assess a country’s eye health system, in order to diagnose the relative strengths and weaknesses of the eye health system, to plan, prioritise key weakness areas, and identify potential solutions or recommendations for eye care interventions.

• Assist national eye health authorities and international organisations to include eye health systems interventions in eye care programme design and implementation, and into the general health system.

The EHSA approach is designed to provide a rapid and yet comprehensive assessment of the key health systems functions as they relate to eye health, and their interactions, based on the health system ‘building

blocks’ framework elaborated by the World Health Organisation (WHO), as shown in Figure 1:5

Figure 1: Foundations of Health Systems

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