2023 Sierra Leone Human Capital Review ​ aximizing Human M Potential for Resilience and Inclusive Development Report No: AUS0003323 © 2023 The World Bank 1818 H Street NW, Washington, DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved Rights and Permissions This work is a product of the staff of The World The material in this work is subject to copyright. Bank. The findings, interpretations, and conclusions Because The World Bank encourages dissemination of expressed in this work do not necessarily reflect the its knowledge, this work may be reproduced, in whole views of the Executive Directors of The World Bank or or in part, for noncommercial purposes as long as full the governments they represent. The World Bank does attribution to this work is given. not guarantee the accuracy of the data included in this Please cite the work as follows: “World Bank. 2023. work. 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Cover photo: © Moses Alex Kargbo / World Bank Sierra Leone Human Capital Review ​ aximizing Human Potential for Resilience M Inclusive Development and  Photo: © Moses Alex Kargbo / World Bank Table of Contents List of Figures ii List of Tables iv List of Boxes v Acknowledgments vi Abbreviations and Acronyms vii Executive Summary 1 Chapter 1 – Introduction 14 1.1 Country Context 15 1.2 Human Capital and Economic Development 15 1.3 Government’s Commitment to Human Capital Development 16 1.4 Objectives of the Human Capital Review 17 1.5 Data and Methodology 17 1.6 Structure of the Report 19 Chapter 2 – Enabling Environment for Human Capital 21 2.1 National-Level Legislative Frameworks, Policy, and Strategies 22 2.2 Government’s Main Actors 28 2.3 Government Financing of Human Capital 32 Chapter 3 – Human Capital Outcomes in Sierra Leone 42 3.1 Overview of the Human Capital Index 43 3.2 Fetal and Maternal Health During Pregnancy (in Utero) 48 3.3 Infant and Child Mortality, Stunting, and Chronic Malnutrition 56 3.4 School-Based Education 65 3.5 Youth-Oriented Health and Nutrition Services 78 3.6 Employment and Returns to Education in the Working Population 81 3.7 Adolescent Fertility 91 3.8 Life Expectancy, Mortality, and Retirement 97 i Table of contents Chapter 4 – Drivers of (or Challenges to) Human Capital Formation 102 4.1 Poverty 103 4.2 Governance 104 4.3 Financing 105 4.4 Food Insecurity 105 4.5 Gender 107 4.6 Disability and Inclusion 108 4.7 Social Norms 109 4.8 Digital Economy and Innovation 110 4.9 Climate Change 112 4.10 Pandemic and Resilience to Shocks 113 Chapter 5 – Human Capital in Sierra Leone: the Way Forward 117 5.1 Strategic Actions and Policy Recommendations in Core Human Capital Sectors 118 5.2 Priorities and Policy Recommendations in Cross-Cutting Areas 124 References 130 List of Figures Figure 1.1 Main Steps of the Adjusted Problem-Driven Iterative Adaptation Approach 18 Figure 1.2 HCR Workshop with Adolescent Girls in Port Loko, February 2023 18 Figure 2.1 Government Priority Sector by Expenditure, Five-Years Average (2015–2020), Share (%) 32 Figure 2.2 Public Spending Expenditure on Health and Education as Percentage of GDP and HCI 32 Figure 2.3 Trend of Public Education Expenditure 33 Public Spending on Education as Percentage of GDP and Percentage of Total Figure 2.4 34 Government Spending, an International Perspective Figure 2.5 Share of Education Spending by Level 34 Figure 2.6 Equity in Public Spending on Education by Level of Education and Income Level 35 Figure 2.7 Government Public Spending on Health from Domestic Sources 36 Figure 2.8 Recurrent and Capital Health Expenditure, 2015–2019, New SLL Million 37 Figure 2.9 Composition of Recurrent Expenditures on Health 37 Figure 2.10 Budget by Health System Level, 2019–2021, US$ Million 38 Figure 2.11 Equity in Distribution of Health Service Benefits by Income Level 38 Figure 2.12 Per Capita Health Expenditure by District, 2019–2021, US$ 39 Figure 2.13 Composition of Main Social Assistance Spending Over Time, Percent of GDP 40 Sierra Leone Human Capital Review ii Figure 3.1 HCI 2020 and Components 43 Human Capital Scores in Sierra Leone by Social, Economic, and Geographic Factors, Figure 3.2 45 2020 Figure 3.3 Population Age Structure for Males and Females in 1990, 2019, and Forecasted for 2100 45 Figure 3.4 Components of the HCI 46 Figure B.1.1 Human Opportunities Index, Access to Healthcare Services 47 Figure 3.5 MMR in Sub-Saharan Africa, 2019 48 Figure 3.6 Top Five Causes of Under-5 Mortality in Sierra Leone 53 Figure 3.7 Under-5 Mortality (and Sub-Mortality) Rates by Location 57 Figure 3.8 Proportion of Under-5s Sleeping Under an ITN by District 61 Figure 3.9 Access to Improved Water and Sanitation Facilities 62 Figure 3.10 Breastfeeding Status of Children under 2 Years 63 Figure 3.11 ECD Index Composition 65 Figure 3.12 ECE Participation and School Readiness (%) 66 GERs and NERs in Primary, Junior Secondary, and Senior Secondary School, 2003 and Figure 3.13 67 2018 Figure B.3.1 Historical Evolution of Pre-Primary to Senior Secondary School Enrollment, 2010-2020 68 Figure 3.14 Share of OOSC 69 Figure 3.15 GERs by Economic Status 69 Figure 3.16 Results of Reading and Numeracy Test in Grades 2 and 4, 2021 71 Percentage of Children Ages 7–14 Demonstrating Basic Literacy and Numeracy Skills by Figure 3.17 73 Wealth Quintile, 2017 Figure 3.18 Junior Secondary School 2 Student Achievement, 2017–2019 73 Figure 3.19 Learning by Language Spoken at School 74 Figure 3.20 Learning by Language Spoken at School and Home 75 Figure 3.21 Student-Level Factors Related to Learning 76 Figure 3.22 Causes of Adolescent Mortality by Gender (Deaths per 100,000) 79 Figure 3.23 Evolution and Education Profile of the Working Age Population 81 Figure 3.24 Sectoral and Employment Composition in Sierra Leone 82 Figure 3.25 Labor Force Participation by Gender and Location, 2013 and 2018 83 Figure 3.26 Labor Force Participation at Different Stages of Life 83 Figure 3.27 Unemployment Rate, 2003 and 2018 84 Figure 3.28 Returns to Education, 2003 and 2018 85 Figure 3.29 Share of Youth Not in Education, Employment or Training (NEET) 85 Figure 3.30 Employment and Education Status of the Youth by Gender and Location 86 Figure 3.31 Determinants of NEET, Working and Schooling for All Youth 87 iii Table of contents Figure 3.32 Reasons for Not Looking for a Job by Location 88 Figure 3.33 Reasons for Not Looking for a Job by Gender 89 Figure 3.34 Adolescent Fertility Rate by Location (births per 1,000 female adolescents) 92 Percentage of Women Aged 20–24 Who Gave Birth as Adolescents (under 20) and as Figure 3.35 94 Children (under 18 and under 16) Figure 3.36 Probability of Survival from Age 15-60 97 Figure 3.37 Life Expectancy, Regional Comparisons 98 Figure 3.38 Life Expectancy by Gender 98 Figure 3.39 Causes of Male Adult Mortality (deaths per 100,000 persons) 100 Figure 3.40 Causes of Female Adult Mortality (deaths per 100,000 persons) 100 Figure 4.1 Projected Mean Temperature 112 Figure B.4.1 Shortfall in Service Delivery Compared to Pre-Pandemic Levels 116 List of Tables Table 2.1 Main Laws, Policies, and Strategies that Affect Human Capital Development 22 Table 2.2 Government Main Actors 29 Table 2.3 Key Social Assistance Program Coverage, Percentage 41 Table 3.1 HCI Components - Sierra Leone and Comparators 44 Table B.2.1 Distribution of Health Cadres by Ownership and Location 50 Table B.2.2 Availability of Basic and Comprehensive Emergency Obstetric and Neonatal Care 52 Table 3.2 Neonatal Mortality Rates (NNMR) by Key Health-seeking and Fertility Behaviors 54 Table 3.3 Infant and Child Mortality Rates Socio-Economic Characteristics 57 Causes of Mortality among Those Ages 1–59 Months in Sierra Leone Table 3.4 59 (under-5s excluding neonatal deaths) Table 3.5 Gender Difference in Learning 72 Table 3.6 Level of Variation of Learning at School and District 74 Table 3.7 Infant and Child Mortality Rates by Mother’s Age (deaths per 1,000 live births) 92 Sierra Leone Human Capital Review iv List of Boxes Box 1. Inequalities in Access to Healthcare 47 Box 2. Low Quality of Healthcare in Sierra Leone 50 Box 3. Impact of FQSE Policy on Enrollment and its Financial Implication 68 Box 4. Low Levels of School Participation Explained by Women in Sierra Leone 70 Box 5. Poor Learning Outcomes Explained by Teachers and Students 77 Box 6. Adolescent Mental Health in Sierra Leone 80 Box 7. Key Pillars for Creating an Enabling Environment for the Digital Economy 110 Box 8. The Impact of COVID-19 on Sierra Leone’s Health Sector 116 Box 9. Government’s Ongoing Effort to Improve the Quality of Learning 118 Box 10. Strengthening Skills Acquisition 120 Ongoing Effort of Shock-Responsive Social Services under the World Bank-financed Social Box 11. 121 Safety Net Project Government’s Interventions to Improve Access to Quality Essential Obstetric and Neonatal Care Box 12. 122 by Prioritizing Investments with Large, Underserved Communities Box 13. Ongoing Efforts to Leverage Technology in Sierra Leone 128 v Table of contents Acknowledgments This report was prepared by a World Bank team in collaboration with the Government of Sierra Leone. The World Bank team is led by Mari Shojo, Ali Ansari, and Patrick Mullen and comprises Leila Fall, Robert Benjamin Hopper, Seo Yeon Hong, Samik Adhikari, Abu Kargbo, Yohana Dukhan, Hannah Buya-Kamara, Angus Fayia Tengbeh, Robert Sam-Kpakra, Olga Guerrero Horas, Nicolas Rosemberg, and Miriam Theresa Mason Sesay, under the overall guidance of Pierre Laporte (Country Director for Ghana, Liberia, and Sierra Leone), Abdu Muwonge (Country Manager for Sierra Leone), and Scherezad Joya Monami Latif (Education Practice Manager, Western and Central Africa Region). Warrah Mansaray, Florence Kabia, Zainab Mariama Kargbo, and Salieu Jalloh assisted the task team during the preparation of this report. The team is grateful to Lydia Mesfin Asseres, Harsha Aturupane, Caryn Bredenkamp, Laura Rawlings, Jason Weaver, and other reviewers for their valuable feedback throughout the preparation of this report. The World Bank team would like to express their sincere gratitude to all the individuals and organizations who made invaluable contributions to the development of this report. The underlying approach employed in this study sought to empower local stakeholders to comprehend and address intricate challenges pertaining to human capital within their familiar context. We are grateful for the active involvement of the following entities, whose participation greatly enhanced the consultation process and facilitated a comprehensive understanding of the drivers shaping human capital formation. The World Bank team extends its appreciation to all our colleagues at the State House, Ministry of Finance (MoF), Ministry of Health and Sanitation (MoHS), Ministry of Youth Affairs (MoYA), Ministry of Local Government and Community Affairs (MLGCA), Ministry of Employment, Labour and Social Security (MELSS), Ministry of Technical and Higher Education (MTHE), Ministry of Basic and Senior Secondary Education (MBSSE), Ministry of Agriculture and Food Security (MAFS), Directorate of Science, Technology, and Innovation (DSTI), National Youth Commission (NAYCOM), National Commission for Social Action (NaCSA), and Local Councils, for their fruitful collaboration, insights, and guidance. We would like to extend our special thanks to the Human Capital Focal Points for providing their support, insights, and specific inputs to the Report, including Yakama Jones (MoF), Madleen Frazer (MoF), Stephannie Adinde (MoF), and Benjamin Davies (DSTI). We also express our gratitude to Francis Smart (MoHS), Francis Kamara (MELSS), Lansana Keifala (MBSSE), Adama Jean Momoh (MBSSE), Mathias Esmann (MBSSE), Abdul Senesie (MTHE), Sia Fasuluku (MTHE), Victor Sesay (MTHE), Idris Turay (NaCSA), and Henry King (MoYA) for their valuable feedback and active participation during follow-up discussions, which contributed to the completion of this report. Our gratitude also goes to development partners, including UNICEF, UNESCO, USAID, FCDO, IOM, WHO, UNDP, WFP, UNAIDS, World Vision, and CEED-SL for their support during the consultation process, and also representatives of the private sector, including Manufacturers Union, Women in Energy, Africell, Bike Riders Union, Importers Association, Hotel Association, Kekeh Riders Association, Shea and More and Telcos for their active involvement and insights. Furthermore, the World Bank team would like to acknowledge the valuable contributions and perspectives provided by youth groups consisting of university students and graduates, teachers and adolescent girls, and official youth representatives for sharing their experiences and providing valuable inputs. We extend our thanks to the regional officials from Freetown, Bo, Makeni, and Koidu for their valuable insights and participation. Sierra Leone Human Capital Review vi Abbreviations and Acronyms ANC Antenatal Care BEmONC Basic Emergency Obstetric and Neonatal Care BMI Body Mass Index BPEHS Basic Package of Essential Health Services CEmONC Comprehensive Emergency Obstetric and Neonatal Care COVID-19 Coronavirus Disease CSAP Child Survival Action Plan DHS Demographic and Health Survey DSTI Directorate of Science, Technology and Innovation ECD Early Childhood Development ECE Early Childhood Education EMTCT Elimination of Mother-to-Child Transmission of HIV FHCI Free Health Care Initiative FQSE Free Quality School Education GBV Gender-based Violence GDP Gross Domestic Product GER Gross Enrollment Rates GoSL Government of Sierra Leone HCI Human Capital Index HCP Human Capital Project HCR Human Capital Review HIV/AIDS Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome HOI Human Opportunity Index IAF Inter-Agency Forum IYCF Infant and Young Child Feeding IHME Institute of Health Metrics and Evaluation ILO International Labor Organization ITN Insecticide Treated Mosquito Net JSS Junior Secondary School LIC Low-Income Country MBSSE Ministry of Basic and Senior Secondary Education MDSR Maternal Death Surveillance and Response MELSS Ministry of Employment, Labour and Social Security MICS Multiple Indicator Cluster Survey MMR Maternal Mortality Ratio MoF Ministry of Finance MoHS Ministry of Health and Sanitation MoYA Ministry of Youth Affairs MSW Ministry of Social Welfare MTHE Ministry of Technical and Higher Education MTNDP Medium-Term National Development Plan NaCSA National Commission for Social Action NAYCOM National Youth Commission NCD Non-Communicable Disease NCTVA National Commission for Technical and Vocational Awards NDMA National Disaster Management Authority vii Abbreviations and Acronyms NEET Not in Education, Employment, or Training NET Net Enrollment Rate NNMR Neonatal Mortality Rate NSPS National Social Protection Strategy OECD Organization for Economic Co-operation and Development OOSC Out-of-school Children PDIA Problem-Driven Iterative Adaptation PHC Primary Health Care PPH Post-partum Hemorrhages RMNCAH Reproductive, Maternal, New-born, Child, and Adolescent Health RMNCAH&N Reproductive, Maternal, New-born, Child, and Adolescent Health and Nutrition SARA Service Availability and Readiness Assessment SDHI Service Delivery Health Indicator SLIHS Sierra Leone Integrated Household Surveys SSA Sub-Saharan Africa SSN Social Safety Net SSS Senior Secondary School STEM Science, Technology, Engineering, and Mathematics TB Tuberculosis TSC Teaching Service Commission TT Tetanus Toxoid TVET Technical and Vocational Education and Training UNICEF United Nations International Children’s Emergency Fund WASH Water, Sanitation, and Hygiene WHO World Health Organization Sierra Leone Human Capital Review viii Executive Summary Photo: © Moses Alex Kargbo / World Bank Introduction This Human Capital Review (HCR) Report presents an in-depth analysis of human capital indicators throughout a person’s lifetime, from in utero to productive aging. By examining the various stages of human capital accumulation, the report aims to provide accurate recommendations for specific groups in Sierra Leone. Thus, the report disaggregates data whenever possible. It relies on an extensive consultative process involving various stakeholders such as Government counterparts, development partners, teachers, adolescent girls, students, private sector representatives, and local representatives. The consultation process followed a Problem-Driven Iterative Adaptation (PDIA) approach, which facilitates the identification and resolution of problems by local leadership. In addition, this report aims to inform the design and implementation of human capital reforms that will respond to specific challenges identified in the report. Country Context and Human Capital Performance Sierra Leone has faced a series of shocks, including a devastating civil war from 1991 to 2002, the Ebola outbreak in 2014–15, a collapse in international prices for iron ore, the coronavirus disease (COVID-19) pandemic and, most recently, Russia’s invasion of Ukraine. These shocks have led to fiscal stresses, a negative impact on the service sector, inflationary pressures, and an increase in public debt, exacerbating poverty levels. The Government’s official poverty line indicates that more than half of Sierra Leoneans live in poverty, and extreme poverty has been rising. Socio-economic status tends to differ across regions, primarily at the expense of rural areas. Furthermore, Sierra Leone, with a population of 8.4 million, has a Gross Domestic Product (GDP) of US$457 per capita (2022), which classifies the country as a low-income nation. Despite an unfavorable economic landscape, Sierra Leone has made progress in improving key human development indicators in recent years, with significant improvement in under-5 mortality rates, adult survival rates, and under-5 stunting prevalence since 2005. However, Sierra Leone still lags behind some of its regional counterparts in human capital development and ranks 165 out of 174 countries in the 2020 Human Capital Index (HCI). The country’s HCI score was 0.36 in 2020, indicating that a child born in Sierra Leone will only be 36 percent as productive when they grow up as they would have been with complete education and full health. This is below the averages for Sub-Saharan Africa (SSA) and low-income countries. Therefore, Sierra Leone must safeguard its human capital gains, as deficits in the health and education sectors could hinder the productivity of the next generation of workers. The Government has demonstrated its commitment to improving human capital development, yet overlapping crises and resulting fiscal constraints threaten these gains. Therefore, it is essential to invest in improving the quality of education and healthcare to ensure that Sierra Leone’s youth can reach their full potential and that the country can achieve sustained economic growth and development. Sierra Leone Human Capital Review 2 A Demographic Challenge Sierra Leone has experienced a significant drop in mortality rates in recent years combined with continuous high fertility rates, resulting in a large youth bulge in the country. With a fertility rate of 4.2 births per female in 2019, 75 percent of Sierra Leoneans are below the age of 35 and 42 percent below the age of 15. This youth bulge is already straining the country’s services and small economy. However, if the Government can invest in the human capital of its young and dynamic population, there is potential for a demographic dividend, resulting in economic growth. To realize this dividend, Sierra Leone must improve access to quality education and health and facilitate opportunities for its population to enter the labor market. While the share of the working-age population has increased since 1994 and is more educated than ever, a large proportion of the workforce remains uneducated, hindering the ability of human capital to contribute to the country’s economic transformation. Challenges Facing Women, Girls, and People with Disabilities Sierra Leone faces significant challenges in promoting gender equality and empowering women, particularly in human capital accumulation. Sierra Leone’s poor performance in the Gender Inequality Index, where it ranks 162 out of 170, is a clear reflection of the prevailing challenges related to gender inequality in the country. Women and girls are disproportionately affected by the opportunities to accumulate (and the loss of) human capital. One of the primary reasons for dropping out of school is early childbearing and early/child marriage, both of which are prevalent among girls in Sierra Leone. Indeed, more than a quarter of girls marry before age 18, and 14 percent before their sixteenth birthday. These practices have a negative impact on educational attainment, labor force participation, and women’s agency. Moreover, they are likely to affect the health and nutrition of their children, creating a cycle of intergenerational disadvantage. While the Government has taken steps to address gender-based violence (GBV) and gender inequality, much work remains. For example, the legal framework to protect young females from child marriage is not fully effective, as customary practices can bypass the law. Additionally, social and informal institutions and norms also perpetuate gender inequality in family, education, government, and marriage. These inequalities manifest in low decision-making power for women within households, sexual abuse of women in institutions, and high incidence and acceptance of GBV against women. Child marriage reduces girls’ educational prospects. Conversely, more education and employment opportunities for girls reduce the likelihood that they will marry early. However, the COVID-19 crisis and the associated economic downturn are likely to be especially damaging for adolescent girls, exacerbating the prevalence of child marriage and early childbearing and increasing the risk of dropping out of school. This was the case during the 2014–15 Ebola epidemic, which disrupted schooling and contributed to an increase in adolescent pregnancy. Therefore, promoting gender equality and empowering women requires concerted efforts from multiple stakeholders, including the Government, civil society organizations, and development partners. These efforts should enhance the legal framework to protect young girls from child marriage, improve access to education, reduce GBV, increase women’s participation in decision-making processes, and create opportunities for decent employment. These steps are essential for building a more inclusive and sustainable society in Sierra Leone. Concerning persons with disabilities, Sierra Leone has made progress in including this group in policies and programming over the past decade. The Government has prioritized this group in social protection programs, including cash transfers and in-kind commodities during the COVID-19 pandemic. With priority targeting for 3 Executive Summary persons with disabilities in urban areas, 44 percent of beneficiary households in the Government of Sierra Leone’s flagship Social Safety Net Project are households with at least one person with disabilities. However, further progress requires addressing specific barriers, such as the lack of inclusive teaching practices and support facilities in education and ensuring adequate funding for programs targeting persons with disabilities. The availability of relevant data is also necessary for insights into demographics and specific needs. GoSL has conducted nationwide registration of persons with disabilities through the National Commission for Social Action. Dissemination and incorporation of such data into a social registry would be key in informing policy and designing coordinated programs that target persons with disabilities. Health Challenges Maternal mortality and reproductive health Sierra Leone has made significant progress in reducing maternal mortality rates due primarily to the implementation of the Free Health Care Initiative (FHCI) in 2010, which eliminated user fees for pregnant women, lactating mothers, and children under the age of 5. This has resulted in increased use of pre- and post-natal healthcare services and assisted deliveries across the country. However, despite these gains, maternal mortality remains a significant public health issue, with Sierra Leone having one of the highest maternal mortality rates in the world – 443 deaths per 100,000 live births in 2020. Maternal mortality in Sierra Leone is driven by several factors, including a high fertility rate, the prevalence of high-risk fertility behaviors, and – most notably – the country’s poor quality of healthcare. Sierra Leone also experiences shortages of skilled healthcare workers, and there is an unequal geographic distribution of staff, particularly impacting rural communities, with only two skilled health personnel per 10,000 inhabitants. For example, 40 percent of all midwives are based in Freetown, with only 29 percent in rural communities, despite 57 percent of the country’s population living in rural areas. While shortages of staff have a severe impact on the effective access to quality health services, even where health workers are present, the quality of maternal healthcare is typically poor. Only 31 percent of clinicians assessed by the Service Delivery Health Survey adhere to clinical guidelines for managing maternal and neonatal complications, indicating a low level of knowledge. The inequitable distribution of health workers and the limited availability of priority drugs further complicates the already challenging task of ensuring adequate and effective healthcare delivery across the country, particularly in rural communities. Moreover, despite the FHCI, Sierra Leoneans still report high out- of-pocket expenses for health services. In countries with high fertility rates, such as Sierra Leone, ensuring access to quality obstetric care (basic and comprehensive) is essential. However, only 9.3 percent of health centers and 2 percent of health posts offer full basic emergency obstetric and neonatal care, and only 1.5 percent of all facilities are equipped to provide comprehensive emergency obstetric and neonatal care. The Government could improve its performance by investing in training healthcare workers to enhance their capacities and knowledge. This should be paired with investments in medical equipment and supplies to enable them to operate effectively. Child malnutrition and mortality Despite efforts to improve child health and nutrition in Sierra Leone, infant and child mortality rates remain alarmingly high. With only 88 out of 100 children born today expected to survive to the age of five, Sierra Leone has some of the world’s highest infant and child mortality rates. Wealthier, urban, and better-educated mothers have lower infant and child mortality rates, indicating a clear nexus between socio-economic status and child survival. Additionally, Sierra Leone struggles with high child malnutrition rates, with 30 percent of under-5s stunted in 2019. Data from the Democratic and Health Survey (DHS) 2019 indicate that the majority of children aged 6–23 months do not meet their minimum meal frequency or receive an adequately diversified diet. Furthermore, only 54 percent of children under 6 months were exclusively breastfed in 2019, Sierra Leone Human Capital Review 4 and complementary feeding practices are often introduced too early, increasing the risk of mortality due to infection. Addressing child mortality and malnutrition in Sierra Leone requires multi-sectoral approaches that address socio-economic inequalities and improve access to diversified diets and healthcare services. Overall, the major causes of maternal, neonatal, and under-5 mortalities are dominated by preventable and treatable causes, emphasizing the importance of improving healthcare quality and access. Although preventive measures like vaccination are crucial in early ages, the basic immunization rate for children aged 12–23 months has experienced a decline from 68 percent in 2013 to 56 percent in 2019. In addition, inadequate water, sanitation, and hygiene (WASH) practices are significant challenges, as only two-thirds of Sierra Leoneans have access to appropriate clean water. Poor nutritional practices and a lack of diversity in diets contribute to stunting and child malnutrition – impairing cognitive and physical development – and mortality. Poor Learning Outcomes, Participation, and Barriers to Quality Education Sierra Leone still faces significant challenges in providing quality education for all children. Although the percentage of out-of-school children (OOSC) has decreased, the figures remain high, with one out of five children out of school. Despite improvements in access to education, learning outcomes remain very low. Children lack basic foundational literacy and numeracy skills, as evidenced by a harmonized test score of 316, where 625 represents advanced attainment and 300 represents minimum attainment. Only 12 percent of children aged 36–59 months participate in early childhood education, and only 13 percent are considered ready for elementary school (Multiple Indicator Cluster Survey [MICS], 2017). Furthermore, urban areas tend to outperform rural areas in foundational literacy and numeracy skills, reflecting imbalances in the quality of education. Similarly, this gap between urban and rural areas is apparent in school readiness. While 30 percent of children in urban areas are prepared for school, this figure drops to just 4 percent in rural areas. Several factors contribute to poor learning outcomes, such as inadequate financing of education, insufficient funding for resources and training for teachers, inadequate teacher training and supervision, weak school leadership, a lack of prioritization of foundational learning, and low levels of community engagement in education. Many students face various forms of abuse and feel disenfranchised, both inside and outside the classroom. Other reasons for low school participation are many and manifold. They include poverty, parents’ perceptions that schooling is not effective, high-stakes exams and repetition, harassment, social norms, lack of self-belief, and early pregnancy due to poor sex education and reproductive health services. Girls in many communities cannot afford education, face sexual abuse and harassment in schools, experience pressure to marry early, and lack role models to encourage their academic and intellectual abilities. These factors contribute to high dropout rates for girls, emphasizing the need for urgent action to address these challenges and provide equal access to quality education for all children while promoting targeted policies for the disadvantaged. 5 Executive Summary Youth Employability Significant challenges in Sierra Leone include relatively low levels of youth labor force participation and high levels of youth engagement in vulnerable occupations. According to the data, 23 percent of youth aged 15 to 24 are not in education, employment, or training (NEET). In addition, there are significant disparities between rural and urban areas in youth employment, with 61 percent of youth employed in rural areas, compared with 35 percent in urban areas. Statistics also reveal that 23 percent of youth who have completed secondary education are underemployed, which is higher than the 11 percent without formal schooling. Analogically, senior secondary or higher technical and vocational education and training (TVET)-educated youth are more likely to be NEET than primary or less-educated youth, reflecting the lack of opportunities for skilled labor in the job market. Youth employability in Sierra Leone faces several challenges. Some of the main obstacles to finding work include financial constraints, lack of skills/experience, and family responsibility (the latter pertaining to women). Moreover, low educational attainment and the low quality of education inhibit many individuals from securing employment, and the undiversified economy leads to a lack of opportunities for the youth. Agriculture, which employs many, fails to provide people with sufficient income to escape the poverty trap due to low productivity. Additionally, numerous barriers to doing business in Sierra Leone limit the potential for self-employment, while a skills mismatch between supply and demand persists. Employers face challenges in filling job vacancies due to candidates’ low technical skills and lack of practical experience. The lack of inclusive and sustainable policies also hinders youth employability in Sierra Leone. Despite the Government’s efforts to create employment initiatives, the policy-making process lacks inclusiveness and democratic participation, funding to sustain reforms, and consistency. Finally, high rural–urban migration rates of the uneducated workforce exacerbate the youth employment challenge. Many young people leave rural areas, searching for better opportunities and infrastructure in urban regions. However, without the necessary skills and educational qualifications, they face a shortage of employment opportunities, leaving them vulnerable to social vices such as cultism, crime, and drug abuse. Sierra Leone Human Capital Review 6 Underlying Cross-Cutting Issues The HCR also identifies cross-cutting bottlenecks that need to be addressed for sustainable and equitable human capital formation: a. Poverty rates remain persistently high in comparison with other SSA countries. Rural areas bear the greatest burden, experiencing double the incidence of poverty compared with urban areas. Despite commendable efforts to combat poverty through social safety-net programs and initiatives offering free healthcare and education, challenges such as inefficiencies in reaching the intended beneficiaries and the inadequacy of cash transfer benefits and coverage persist. b. Weak governance, management, and accountability systems hinder effective service delivery in Sierra Leone. Although the Local Government Act (2004) delegated the responsibility for health and basic education service delivery to local councils, practical implementation faces numerous obstacles. Challenges include a weak regulatory environment, inadequate quality assurance and monitoring systems, and fragmented and under-used sector management information systems. c. Insufficient funding poses a barrier to investing in interventions aimed at enhancing human capital. There has been an increase in Government spending on human capital. However, the existing financial gap hampers the implementation of development strategies and the improvement of human capital outcomes. The effective financing of essential capital and non- recurring expenses is crucial, as the mishandling of costs can greatly hinder the provision of education and healthcare services. Cost burden, especially for poor families (e.g., out-of-pocket expenditure), is a key factor preventing equitable access to education and health services. d. Food insecurity is also a critical and escalating issue in various domains, including nutrition, health, education, and employment. The primary cause of this predicament is the limited availability of nutritionally diverse foods stemming from outdated agricultural practices, insufficient inputs, substantial harvest losses, inadequate market access, and elevated food prices. e. Discriminatory social norms and cultural practices contributing to inequality constrain the capacity and opportunity of people, especially women and individuals with disabilities. Women in Sierra Leone tend to have limited decision-making power across various levels, including within households, communities, and the nation. Also, discriminatory social norms and stigmatization limit the meaningful participation of individuals with disabilities in society, compounding the challenges they already face. f. Pandemic and vulnerability to shocks. Sierra Leone has faced numerous economic shocks in recent years, including the Ebola crisis, a decline in iron ore prices, the COVID-19 pandemic, and, more recently, Russia’s invasion of Ukraine. The country ranks among the top countries most vulnerable to the adverse impacts of climate change, with the education and health sectors being particularly susceptible. 7 Executive Summary Strategic Directions and Policy Recommendations The table below summarizes key policy recommendations to improve human capital outcomes. Overview of Key Policy Options Policy Time Responsible Objective recommendation Frame government agencies Education, Youth Skills and Employability Prioritize Increase access to schooling, investments particularly at the early childhood S MBSSE in high-impact education level and secondary level interventions in education for Pay special attention to addressing MBSSE in collaboration disparities in access to quality foundational S with other agencies such education, and promote gender learning as MGCA, NaCSA, MSW equality and inclusive education Improve the quality of teaching and S MBSSE, MTHE prioritize learning Tackle demand-side barriers to MBSSE in collaboration S to M education services with other agencies Improve the Develop and implement staff education sector management systems to attract S MBSSE, MTHE, MoF and workforce and retain the best-caliber education management workforce Ensure more effective deployment of teachers by leveraging robust data, S to M MBSSE, MoF and use preference match models for teachers Sierra Leone Human Capital Review 8 Policy Time Responsible Objective recommendation Frame government agencies Education, Youth Skills and Employability Prioritize Improve the quality and relevance of investments S to M MTHE, NCTVA, TEC TVET and higher education sectors in high-impact interventions for youth skills and Strengthen partnerships with employability industry to increase involvement in S MTHE, MELSS, NCTVA skills training Re-align skills training course offerings to those for which there S MTHE, NCTVA is demonstrated demand from the labor market Reform/formalize the apprenticeship S MTHE model Support individuals to establish their enterprises or scale up their S MELSS businesses Provide complementary services such as basic digital and financial literacy, start-up grants, climate S MELSS, MTHE, MoYA, NAYCOM change education and linkages to relevant Government services Increase opportunities to access credit for women and enhance access S MELSS, NaCSA, MGCA to affordable childcare services Collect more regular data on labor S to M MELSS market outcomes for youth Health Prioritize Improve access to quality essential investments obstetric and neonatal care S to M MoHS in high-impact interventions in health Improve the functionality of the S MoHS emergency referral system Invest in sexual health education S MoHS, MBSSE Increase the availability of youth- friendly family planning services to S MoHS ensure its availability for adolescents MoHS in collaboration with other Tackle demand-side barriers to S to M ministries including MBSSE, MTHE, health services NaCSA, MGCA and MSW 9 Executive Summary Policy Time Responsible Objective recommendation Frame government agencies Health Improve Develop and implement staff investment management systems to attract in the health S MoHS, MoF and retain the best caliber health workforce workforce management Social Protection and Jobs Prioritize Enact the Social Protection Bill investments and operationalize to ensure a in ensuring a minimum social protection floor and S NaCSA, NSPS, MELSS, IAF minimum social age-appropriate social protection interventions that will benefit all protection floor Sierra Leoneans for all Sierra Leoneans Strengthen social protection systems by improving targeting and S NaCSA efficacy Invest in social protection systems that will allow interoperability across sectors (health and education) to optimize delivery and improve S to M NaCSA, NSPS, MELSS, IAF efficiency and effectiveness of social protection services and delivery costs Regularly collect and disseminate detailed and high-quality data on S NaCSA, NSPS, MELSS, IAF social assistance, social insurance, and labor market programs Continue strengthening and scaling up key social protection programs, especially to support the bottom S NaCSA, NSPS, MELSS, IAF 40 percent of the population, largely employed in subsistence agriculture Expand interventions that support S to M NaCSA, NSPS, MELSS, IAF informal sector workers Prioritize investments in S to M MoF, NaCSA, NSPS, NDMA risk-financing mechanisms Sierra Leone Human Capital Review 10 Policy Time Responsible Objective recommendation Frame government agencies Financing Increase Increase fiscal space for human MoF and human and improve M development sectors capital-related ministries investment in sectors related to human capital Reprioritize spending with a focus on interventions that have proven MoF and human S effective and target the poor and capital-related ministries vulnerable Expand coverage of social protection MoF and human S to M programs capital-related ministries Reduce households’ out-of-pocket M MoF, MoHS, MBSSE, and MTHE expenditure for health and education Cross-cutting Areas Promote All human capital-related Rely on accurate data to inform evidence-based S ministries, in collaboration with decision-making decision-making other agencies Collect more regular information All human capital-related on sector delivery outcomes and S ministries, in collaboration with beneficiaries, and service other agencies Improve All human capital-related Strengthen human resource governance S ministries, in collaboration with management and strengthen other agencies implementation capacity Improve data management and use All human capital-related S ministries, in collaboration with data for improved service delivery other agencies All human capital-related Build strong partnerships S ministries, in collaboration with other agencies Improve Government’s human capital focal Create a forum for a Human Capital national- and S points of human capital-related Coordinating Platform local-level ministries coordination in human capital Convene regular meetings of key stakeholders at national and local development council level, including representation Government’s human capital focal in the realms of education, health, S points of human capital-related social protection, agriculture, gender ministries and children’s affairs, and water resources management 11 Executive Summary Policy Time Responsible Objective recommendation Frame government agencies Cross-cutting Areas Build resilient Leverage to provide support to NaCSA, NSPS, DSTI, and other and adaptive affected citizens during climate, S to M human capital-related ministries human health, and economic shocks development systems Develop risk management and risk- NaCSA, NSPS, DSTI, and other S financing mechanisms human capital-related ministries Invest in well-targeted social NaCSA, NSPS, DSTI, and other S interventions human capital-related ministries Improve food Strengthen agricultural productivity security by enhancing agricultural research S MAFS and MoHS and development, and improve access to quality inputs services Enhance access to nutritious food by promoting nutrition-sensitive agriculture, improving food S MAFS and MoHS accessibility, and providing cold chain facilities Build resilience to climate change through targeted investment and the S to M MAFS and MoHS development of risk management mechanisms Tackle Promote community engagement, All human capital-related social-cultural including religious groups, to promote S ministries norms positive behavior Develop sensitization programs to All human capital-related S promote social inclusion ministries Ensure that the education curriculum S MBSSE is gender sensitive Introduce mentoring and career guidance programs to support young women in pursuing male-dominated S MTHE, MoYA NAYCOM, MBSSE courses or careers and support ongoing scholarship initiatives for women studying STEM Leverage Prioritize the provision of basic MoHS, MBSSE, MTHE, DSTI, technology to infrastructure such as electricity and S to M and Ministry of Information and improve health internet services, enablingcitizens to Communications and education fully reap the benefits of innovation service delivery Enhance and encourage technology MoHS, MBSSE, MTHE, DSTI, that supports teaching and learning S and Ministry of Information and as well as health and education Communications delivery Sierra Leone Human Capital Review 12 Policy Time Responsible Objective recommendation Frame government agencies Cross-cutting Areas Ensure human Prioritize women, people with MoHS, MBSSE, MTHE, NSPS and capital disabilities, poor households, youth S NaCSA interventions who are NEET, and rural youth are targeted to vulnerable Use data to identify these vulnerable MoHS, MBSSE, MTHE, NSPS and groups S groups NaCSA Employ tailored approaches to target All human capital-related different groups by considering the S ministries, in collaboration with intersectionality of issues other agencies Operationalize existing policies which All human capital-related target these groups and ensure that S ministries, in collaboration with there is adequate financing other agencies Protect and Address legal inconsistencies MoHS, MBSSE, MTHE, in empower women between national and customary M collaboration with other ministries and people with laws to prevent marriage before 18 including MGCA and MSW disabilities Enhance female representation in MoHS, MBSSE, MTHE, in decision-making institutions by S to M collaboration with other ministries implementing affirmative-action including MGCA and MSW measures Implement inclusive education MoHS, MBSSE, MTHE, in policies that prioritize the education S collaboration with other ministries of women and girls and facilitate the including MGCA and MSW enrollment of people with disabilities MoHS, MBSSE, MTHE, in Provide financial support for girls to S collaboration with other ministries stay in school including MGCA and MSW Address social norms perpetuating GBV and ensure that victims of MoHS, MBSSE, MTHE, in sexual exploitation and violence have S collaboration with other ministries access to legal aid and transparent including MGCA and MSW resources at little or no cost Facilitate access to reproductive MoHS, MBSSE, MTHE, in health services, including family S collaboration with other ministries planning and disability-inclusive including MGCA and MSW health services Note 1: S and M refer to short-term and medium-term, respectively, as an assessment of the time frame for the implementation of the given policy. Note 2: For each objective, the policies are listed from the most to the least pressing. 13 Executive Summary Chapter 1 Introduction Chapter 1 delves into Sierra Leone’s macroeconomic and poverty context. It also explores the interconnection between human capital and economic development, and highlights the Government’s dedication to enhancing human capital. This initial chapter further elucidates the report’s objectives and methodology, setting the stage for a comprehensive analysis. Photo: © Moses Alex Kargbo / World Bank 1.1 Country Context Sierra Leone’s economic and social development has been challenged by a series of shocks. With a population of 8.4 million (2021), Sierra Leone is a small country in West Africa bordered by Guinea, Liberia, and the Atlantic Ocean. The country is among the poorest in the world, with a per capita gross domestic product (GDP) of US$457 (2022). With agriculture and mining accounting for two-thirds of economic output, the country is susceptible to fluctuations in global commodity prices. A series of shocks have set back Sierra Leone’s economic development. A devastating civil war between 1991 and 2002 was followed by a period of recovery. However, in 2014–15, the Ebola virus disease outbreak caused approximately 4,000 deaths and had disastrous economic consequences, which, combined with the fall in global commodity prices, contributed to a loss of 20.6 percent of GDP in 2015. In 2020, the COVID-19 pandemic led to fiscal pressures amid lockdown measures, contributing to a slowdown in economic activities and to growth contraction by 2 percent (World Bank, 2023). The rebound in growth in 2021 (4.1 percent) supported by the resumption of iron ore export following the lifting of lockdown measures and return to normal economic activity was brief, being adversely affected by Russia’s invasion of Ukraine in 2022, which led to global supply disruptions and global monetary tightening. Despite global economic conditions, growth performed better than expected in 2022, estimated at 3.6 percent. This growth was driven by robust agriculture, gains in iron ore mining, and fiscal stimulus, which came at the cost of higher inflation and fiscal deterioration. Inflation rose to 37 percent (27 percent on average) in 2022, while the currency depreciated by 40 percent. Public debt increased to 96 percent of GDP against the backdrop of higher fiscal deficit (9.6 percent) and currency depreciation. Growth is projected to contract to 3.3 percent in 2023, largely on account of fiscal consolidation and weak aggregate demand. Inflationary pressure has persisted in 2023 with inflation rising to a 26-year high of 45 percent (year-on- year) in July, while food inflation of 60 percent (year-on-year) has intensified food security concerns. More than half of the Sierra Leonean population lives in poverty, which has failed to decline since 2011. In 2018, prior to COVID-19, the Gini coefficient – which measures income inequality – was 0.357, slightly higher than in 2011. Although international poverty (US$2.15/person/day 2017 PPP) rates have declined since 2020, it remains higher than the pre-pandemic levels. The international poverty is projected at 25 percent in 2023, nearly the same level as 2019, due largely to the cumulative effects of economic contraction in 2020, followed by rising inflation, particularly food inflation, which disproportionately affects the poor. However, applying the Government’s official poverty line, 57 percent of Sierra Leone’s population was considered poor, with significant disparities between urban and rural populations and across provinces. The predominantly urban Greater Freetown region had a poverty rate of 23 percent, the lowest in the country, while the Northern Province recorded the highest rate at 76 percent. A decline in poverty of 5 percentage points between 2011 and 2018 was solely due to improvements in urban areas. Extreme poverty increased from 9 to 13 percent in rural areas while remaining unchanged nationally. Given the contraction in the economy in 2020, the impact of the COVID-19 pandemic and the current crisis, poverty is expected to increase. A recent food security assessment suggests that poverty may be deepening, especially in rural areas (World Bank, 2022a). 1.2 Human Capital and Economic Development Investment in Human Capital is critical to Sierra Leone’s development. Human capital consists of the knowledge, skills, and health that people accumulate over their lives. Along with its intrinsic value, human capital enables an individual to realize their potential as a productive member of society. Higher levels of human capital are associated with higher earnings for people, higher income for countries, and stronger cohesion in societies. It is a central driver of sustainable growth and poverty reduction. The Human Capital Index (HCI), launched in 2018, provides an international metric for human capital investment across countries. The HCI reflects the human capital that a child born today can expect to attain by adulthood, highlighting how current health, nutrition, and education outcomes shape the productivity of the next generation of the workforce. It allows countries to track changes in human capital over time and whether they provide a suitable environment for individuals to thrive (Martin, 2018). The very concept of the human capital index recognizes that not everyone is born with the same health and education capital. The degree of accumulated human capital has implications for an individual’s productivity and, by extension, for the overall economy of their country. Indeed, studies have shown that countries with good education and health performance are 15 Chapter 1 - Introduction more likely to have prosperous economies (Bloom et al., 2004; Hanushek and Woessman, 2008; Barro, 2013; Qadri and Waheed, 2014; Ogundari and Awokuse, 2018). Education and health are critical components of human capital. A healthy workforce can be more productive than a physically or mentally ill workforce, unable or unfit for work (Mayer, 2001). Health is the absence of disease, a non-replaceable good that enables a human being to think, work, and thrive. A healthy mind and body are essential for labor productivity, which is the engine of economic growth. An educated workforce is more likely to provide the skills needed for the labor market and to drive job creation. Knowledge and know-how are potent tools, leading to greater creativity and technological change and stimulating economic growth. Understanding and adapting to change requires advanced skills (Becker et al., 2011; Che and Zang, 2018). Education and health exhibit a mutually reinforcing relationship. Education is a driving force behind an individual’s willingness to adopt a healthy lifestyle and to understand effective health practices. Conversely, being healthy facilitates intellectual capacity and strengthens cognitive skills, the latter being conducive to the accumulation of knowledge. Stunted children, for instance, frequently experience poor academic performance and reduced productivity in adulthood (Black et al., 2017). Overall, a healthy and educated individual will be more productive, which alone makes them more likely to have a higher income, greater purchasing power, more opportunities to consume goods and services produced by society, benefit from preventive health care, and pass on a human capital-intensive legacy to their offspring. 1.3 Government’s Commitment to Human Capital Development Over the past few years, the Government has made significant strides toward improving human capital. The analysis provided in this HCR is intended to inform the design and implementation of reforms in the human capital sector in Sierra Leone. This review is aligned with the Government’s Medium-Term National Development Plan (MTNDP) for 2019–2023, which outlines the country’s vision and strategy for human capital development. The MTNDP comprises eight policy clusters, with ‘Human Capital Development’ being the first, as there is recognition that investments in youth and public services provision are critical for poverty reduction and prosperity for all. The Government is focusing on six broad result areas, including: (a) ensuring free quality basic and senior secondary education; (b) strengthening tertiary and higher education; (c) accelerating healthcare delivery; (d) enhancing environmental sanitation and hygiene; (e) increasing social protection; and (f) advancing housing and land management. The MTNDP for 2019–2023 is complemented by other sectoral plans and policies related to human capital development. For example, in the health sector, the Sierra Leone 2021–2025 National Health Policy (NHP) and the 2021–2025 National Health Sector Strategic Plan (NHSSP) serve as supplements to the MTNDP to guide healthcare financing and delivery, with the overarching goal of achieving Universal Health Coverage by 2030. In addition, the Government’s flagship Free Quality School Education (FQSE) Program, launched in 2018, is among the main policies underpinning national strategies in education delivery. It aims to provide free quality education to all school-going-age children from pre-primary to secondary school and has resulted in an increase in the portion of the national budget allocated to education. In addition, the Education Sector Plan 2022–2026 lays out core education priorities and presents a road map to achieve the country’s education goals. Regarding social protection, the National Social Protection Policy (NSPP) was adopted by the Government in 2011 to target the most vulnerable groups. This policy is supplemented by three major social protection programs: cash transfers to the poorest populations with children; a social pension for war victims and the elderly; and a permanent public work program for those exposed to food insecurity, who suffer from seasonal and permanent unemployment. The HCR provides a crucial tool for advocating for change in the face of persisting challenges.Despite this commitment, there remains scope for improvement in human capital outcomes in the country. The challenges posed by high rates of poverty, low learning outcomes and literacy rates, and limited access to quality education and healthcare continue to persist as significant concerns. The HCR serves as a diagnostic tool for the Government of Sierra Leone to assess human capital outcomes and to identify key contributing factors to low health, education, and social protection outcomes, as well as policy recommendations. The following section provides a more detailed insight into the objectives of the review. Sierra Leone Human Capital Review 16 1.4 Objectives of the Human Capital Review Given the strategic significance of human capital, the Sierra Leone HCR aims to analyze the country’s human capital outcomes and to identify the factors contributing to its low performance. To this end, the analysis is centered on a life-cycle approach and focuses on several indicators, particularly on issues pertaining to women and youth. Overall, the three main sub-objectives of this report are: 1. Analyzing human capital outcomes. This report includes a descriptive analysis of Sierra Leone’s HCI score and the underlying indicators, including survival rates, stunting rates, school enrollment, student learning, and adult survival rate. The report also investigates other relevant human capital indicators such as immunization rates, labor force outcomes, fertility rates, maternal mortality rates, and additional education and health outcomes. This section of the report is structured according to the life-cycle approach. 2. Identifying factors contributing to (or associated with) low human capital outcomes.  The analysis identifies these factors through a quantitative and qualitative approach, as described in the next section. The aim is to triangulate findings and provide a comprehensive understanding of the underlying factors contributing to poor human capital outcomes. 3. Identifying potential solutions to human capital challenges. After identifying issues and possible entry points to address those issues, the review presents policy recommendations to address the main factors inhibiting human capital development. 1.5 Data and Methodology Both quantitative and qualitative methods and data were employed to highlight human capital challenges and solutions in Sierra Leone. The quantitative approach aimed to identify correlates of human capital outcomes for selected indicators. Using the life-cycle approach to frame the discussion, a descriptive analysis highlighted the relevant indicators for early childhood, childhood, adolescence/youth, working age, and productive aging. The life-cycle approach in human capital captures five critical stages of an individual’s expected life trajectory, given the risks of poor health and education prevalent in the country of birth. The cycle of life begins in the womb, i.e., in utero. It continues with survival before the age of 5 in the early years of childhood. Then, from 5 to 19 years of age, it is the time when basic institutional education comes into play. Next follows the period of active adulthood, from age 15 to 64, before the final stage, life after age 60. Where possible, the analysis is disaggregated by sex, socio-economic status, and in some cases, by region. Inferential data analysis was also conducted for selected indicators to identify the correlates of human capital outcomes. The qualitative approach allowed for identifying the root causes of the leading human capital challenges and potential entry points for addressing them. Primary data was obtained through in-depth consultations in Freetown, Bo, Makeni, Koidu, and Port Loko. Key stakeholders were involved, including Government partners, regional officials, development partners working in education and health, private sector representatives, youth groups, human capital focal points, adolescent girls, and other stakeholders such as teachers. These consultations were conducted using an adapted version of the Problem Driven Iterative Adaptation (PDIA) approach, a participatory and collaborative approach where participants help construct and deconstruct major problems into their root causes and then identify entry points to address them. The method rests on four core principles: local solutions for local problems; pushing problem driven positive deviance; try, learn, iterate, adapt; and scale through diffusion. For this review, the PDIA approach was adapted to three stages, presented in Figure 1.1. After presenting the preliminary quantitative findings of the HCR, participants were first asked to identify and ‘construct’ the critical problem(s) in human capital development and their relative importance before deconstructing these problems into root causes. Participants then had to work together to identify multiple solutions to address the human capital challenges or to ‘crawl the design space’ of change. A set of guiding questions was used for each consultation session to facilitate the discussion. 17 Chapter 1 - Introduction Figure 1.1 Main Steps of the Adjusted Problem-Driven Iterative Adaptation Approach Source: Adapted from Samji et al., (2018) PDIA Toolkit. Figure 1.2 HCR Workshop with Adolescent Girls in Port Loko, February 2023 Photo: © Miriam Mason-Sesay / World Bank. Sierra Leone Human Capital Review 18 In addition to the primary data collected, the HCR builds on previous work and draws on quantitative and qualitative methods. Various data sources were used to conduct quantitative analyses, including the Sierra Leone Integrated Household Surveys (SLIHS) (2004, 2011, and 2018); Multiple Indicator Cluster Surveys (MICS) (2005, 2010, and 2017); Sierra Leone Demographic and Health Survey (DHS) (2008, 2013, and 2019); Sierra Leone Health Service Delivery Indicator Survey (HSDIS) (2018); The Sierra Leone Labor Force Survey (LFS) (2014); and administrative education and health data sets (e.g., Annual School Census). Qualitative sources that were reviewed include the Human Capital in Sierra Leone (2020) report, the Public Expenditure Review (PER) Reports for Basic Education, Health and Social Assistance Program (2021), Salone Youth: Addressing Constraints to Youth Employment in Sierra Leone (2020), Sierra Leone Economic Update: The Power of Investing in Girls (2020), Optimizing Nutrition Investment in Sierra Leone (2021), and Teachers and Teaching in Sierra Leone (2021). In addition, the HCR will draw on other regional and global World Bank analyses in the human development sector, among other relevant academic sources. 1.6 Structure of the Report The HCR consists of five chapters. The first chapter serves as the introduction, while Chapter 2 presents the enabling environment for human capital. Chapter 3 presents the main analysis and findings of key human capital indicators in Sierra Leone, identifying the key factors inhibiting human capital growth. Chapter 4 discusses cross-cutting issues impeding human capital development. The last chapter of the review presents policy recommendations. The chapters are described briefly below. Chapter 1. Introduction. This chapter briefly summarizes the country context, including the macroeconomic context and the critical development challenges. Then, the chapter presents the objective of the review, the main research questions, and the data and methodology used for addressing the research questions. Chapter 2. Enabling Environment for Human Capital. This chapter commences with a discussion of the policies governing human capital in the country. It also discusses resource allocation for the human development sector. Next, it identifies the key stakeholders responsible for delivering human capital services along with a presentation of the organization and financing arrangements. The key questions addressed in this chapter are the following: a. What key human capital-related policies and legal frameworks are in place to accelerate human capital development in Sierra Leone? b. How are human capital line ministries structured, and what are the main roles and responsibilities of the key actors? c. How much does the Government spend on financing human capital services, and what are the main challenges in public financing? Chapter 3. Human Capital outcomes in Sierra Leone. Chapter 3 presents a detailed analysis of Sierra Leone’s HCI score and the underlying indicators. The analysis is structured according to the life-cycle approach with indicators presented for early years, childhood, adolescence/youth, working age, and productive aging with disaggregation where data allows. The central research questions addressed in this chapter are: a. How does Sierra Leone fare in terms of human capital outcomes? b. To what extent do human capital outcomes and utilization of human capital differ by sex, socio-economic, and geographic characteristics? Chapter 4. Drivers of (or challenges to) Human Capital Formation. Chapter 4 identifies the main factors inhibiting sustainable and equitable human capital formation, focusing on broad cross-cutting issues such as governance, gender, food security, poverty, and social norms. The core research question of this chapter is: a. What are the transversal issues impeding human capital formation? 19 Chapter 1 - Introduction Chapter 5. Human Capital in Sierra Leone: The Way Forward. This concluding chapter aims to identify and propose policy interventions/reforms for human capital development. These recommendations stem from consultative sessions with counterparts as part of the PDIA process. The chapter addresses the following question: a. What policy reforms should be prioritized to improve human capital outcomes and the utilization of human capital in Sierra Leone? Photo: © Moses Alex Kargbo / World Bank Sierra Leone Human Capital Review 20 Chapter 2 Enabling Environment for Human Capital This chapter provides an overview of the institutional landscape and presents the enabling environment for human capital in Sierra Leone. It first describes the main actors in human capital development and the legislative frameworks, policies, and strategies governing human capital in the country. This analysis will improve understanding of the systems related to the human development sector and identify the factors that drive or block changes in the country’s policies or practices. The chapter also discusses resource allocation for human capital. Photo: © Moses Alex Kargbo / World Bank 2.1 National-Level Legislative Frameworks, Policy, and Strategies National-level legislative frameworks, policies, and strategies, which set out rules or plans of action, influence the behavior of stakeholders and promote or regulate human capital development. The Government has enacted laws and developed policies and strategies to address challenges related to human capital (see Table 2.1). Table 2.1 Main Laws, Policies, and Strategies that Affect Human Capital Development Law/Policy/Strategy Year Description National Development Medium-Term National It stipulates the country’s medium-term strategic Development Plan (MTNDP) 2019 direction, development priorities, and implementation 2019–23 strategies. Governance It provides for the decentralization and devolution of Local Government Act 2004 functions, powers, and services to local councils and other related matters. Education It presents the role and management of the education system at both national and local levels. It seeks to reform the country’s education system, and make the Education Act 2023 basic and senior secondary education system free, accessible, compulsory, relevant, all-inclusive, and rights-based. The sectoral plan, with the theme of ‘Transforming Education Sector Plan Learning For All,’ lays out core education priorities 2022 2022–2026 and presents a road map to achieve the country’s education goals. National Strategy for The national strategy for Out-of-school children in Out-of-school children in 2021 Sierra Leone complements the National Policy on Sierra Leone Radical Inclusion. Policy supporting schooling for all with a particular focus on the inclusion of children with disabilities, National Policy on Radical 2021 children from low-income families, children in rural and Inclusion underserved areas, and girls – especially girls who are pregnant and in school or are parent learners. The policy provides an overarching framework with National Policy on Integrated Early a shared vision, mission, goals, and objectives for 2021 Childhood Development (ECD) delivering holistic ECD interventions and services for all children ages 0 to 8 years. Sierra Leone Human Capital Review 22 The policy aims to ensure school infrastructure improvements are well planned and work towards the MBSSE’s guiding principles of improving universal School Infrastructure and 2021 access to quality education, comprehensive safety, Catchment Area Planning Policy radical inclusion, and quality teaching and learning by providing accessible, safe, and sufficient learning spaces for all children. It delineates the vision and mission of TVET for an effectively coordinated and harmonized system TVET Policy 2019 capable of delivering high-quality market-demand training and skills development programs. The flagship program, dating from 2018, prioritizes Free Quality School Education 2018 free and universal education. It sets out standards of professional behavior for teachers and other education personnel in their The Code of Conduct for Teacher relationships with learners, their colleagues, parents, 2009 and Education Personnel and the general public. It also provides principles to guide professionalism and promote a positive learning environment, as well as the well-being of learners. It provides many of the rights found in the Convention on the rights of the Child and the African Charter of Child Welfare and Rights. In addition, it includes information detailing (a) the setup of a National Child Rights Act 2007 Children’s Commission; (b) specific rights provided; and (c) the specific child welfare functions of local committees and local councils. This Act also enshrines parental responsibility and further outlaws any form of discrimination and exploitation of a minor. Health The overarching goal of this revised strategy is to promote improved health outcomes for women, Reproductive, Maternal, Newborn, new-borns, children and adolescents by adapting an Child, and Adolescent Health and integrated health service delivery approach to ensure 2023 Nutrition (RMNCAH & N) Strategy no opportunities are missed in the implementation 2017 to 2025 of the RMNCAH&N strategy. The extension of the strategy provides an avenue to amalgamate emerging priorities. CSAP aims to reduce under-5 mortality to less than 71 per 1,000 live births by 2025 by refocusing efforts to abolish preventable child deaths in Sierra Leone. It adopts a holistic approach to child health interventions Child Survival Action Plan (CSAP) 2023 by focusing on the period 1–59 months which accounts for about 70 percent of under-5 mortalities in Sierra Leone. It brings together all relevant stakeholders across directorates and programs within the Ministry of Health and Sanitation (MoHS). 23 Chapter 2 - Enabling Environment for Human Capital Given the increase of mother-to-child transmission of Guidelines for the Integration of HIV in Sierra Leone and the low availability of preventive Elimination of Mother-to-Child services for mother-to-child transmission, this national Transmission of HIV (EMTCT) and 2023 guideline seeks to integrate the EMTCT and Pediatric Pediatric HIV into RMNCAH&N HIV into RMNCAH&N and TB programs, all of which and TB programs in Sierra Leone aim to improve maternal and child health outcomes. It seeks to improve access to quality healthcare services and health security for all stages of human Framework for the Person-Centred life devoid of undue financial hardship. The Life Stages Life Stages Approach to Health 2023 approach aims to ensure person-centered holistic Service Delivery care, promotes integration and collaboration across programs and partners, system-wide strengthening, and investment in social determinants of health. It aims to improve the health of school-age children in Sierra Leone by creating a safe, healthy, and enabling School Health Policy 2023 school environment for learning devoid of prejudice, violence, and diseases. The overarching aim of the policy is to address the inherent health system challenges and provide guidance on achieving universal health coverage The National Health and and health security. It seeks to build a resilient 2021 Sanitation Policy (NHSP) and responsive healthcare system to provide comprehensive healthcare services through technology and collaborative partnerships while guaranteeing social protection and equity. Aimed at improving and maintaining the health of the Sierra Leonean population by promoting the establishment of a health system that delivers high- National Health Care and Patient 2020 quality healthcare services that are safe, timely, Safety Policy efficient, effective, accessible, and person-centred by ensuring that care is respectful, responsive, compassionate, and of dignity. It aims to jointly address the issues related to adolescent pregnancy and child marriage and provides National Strategy for the a direction for interventions to address these in the Reduction of Adolescent 2018 country. It also includes a monitoring and evaluation Pregnancy and Child Marriage framework with appropriate milestones and targets for each indicator. This Act of Parliament aims to prevent maternal death and injury, safeguards reproductive rights, and Safe Abortion Act 2015 determines the circumstances and conditions under which pregnancies may be terminated. This policy is to espouse the improved health and social and economic well-being of the people in Sierra Leone, Sierra Leone National Food and 2012 especially women, children, and nutritionally vulnerable Nutrition Security Policy groups, by improving the population’s nutritional status. The policy aims to improve access to quality health care by ensuring that free health care services are Free Health Care Initiative (FHCI) 2010 provided to children under-5, pregnant women, and lactating mothers in all public health facilities in Sierra Leone. Sierra Leone Human Capital Review 24 Revised and updated in 2015 to strengthen the health sector recovery plan post-Ebola, this package The Basic Package of Essential 2010 outlines a list of prioritized, cost-effective and high- Health Services impact interventions that should be provided to every individual at the public health facilities in Sierra Leone. Gender It promotes gender equality in employment and training, Gender Equality and Women’s implements gender mainstreaming and budgeting, and 2022 Empowerment (GEWE) Act instructs financial institutions to prescribe procedures aimed at improving women’s access to finance. Mainstreaming gender into the national, sectoral, and local policies, plans, budgets, and programs to achieve gender equality and women’s empowerment in all Gender Equality and Women’s 2020 spheres of development in Sierra Leone. This is a lawful Empowerment Policy reference point for addressing gender inequalities by all stakeholders at the national and community levels and family units throughout the country. The plan provides a framework and guidelines for institutions implementing gender-related programs. National Gender Strategic Plan 2018 Priority areas include women’s participation in 2018–2023 governance, sexual and reproductive rights, and women’s empowerment. The referral protocol outlines the terms and conditions of coordination and collaboration between relevant 2012 National Referral Protocol on entities involved in sexual and gender-based violence (revised in Gender-Based Violence (SGBV) case management. It describes the roles and 2022) responsibilities across these entities to facilitate a survivor-centered response to reported SGBV cases. It addresses various types of sexual assault and covers married women, children, and people with disabilities. Sexual Offences Act and the 2012 and It also prohibits forced sex in marital relationships and Amendment 2019 protects children from being abused by teachers and traditional and religious leaders. It criminalizes domestic violence and adopts a broad definition of domestic abuse, including sexual, physical, Domestic Violence Act 2007 emotional, psychological, and economic violence perpetrated against an individual in a domestic setting. It addresses women’s inheritance rights by, for instance, protecting widows from being denied access to the property of their deceased spouse, guaranteeing Devolution of Estates Act 2007 the right of children ‘born in and out of wedlock’ to own their deceased father’s property, and ensuring proportionate distribution of property between men and women. It raises the legal age of marriage to 18 years and Registration of Customary 2007 legalizes all marriages under customary, Muslim, Marriage and Divorce Act Christian, and civil laws. 25 Chapter 2 - Enabling Environment for Human Capital Disability and Inclusion Radical Inclusion Policy 2021 See above, in ‘Education’. (for education) The Act prohibits discrimination against persons with disability and aims to achieve equalization of Persons with Disability Act 2011 opportunities for persons with disabilities. The Act also established the National Commission for Persons with Disabilities. Social Protection Following the life-cycle approach, the National Social Protection Strategy discusses priority areas in social protection between 2022 and 2026 to achieve the objectives of the National Social Protection Policy, National Social Protection 2022 2019. It outlines programs needed to reach the goals Strategy (2022–26) of the Policy, incorporating age-appropriate services, gender, and disability. It also outlines the systems that must be established or strengthened to operationalize the programs and provides cost estimates. The Policy promotes the provision of a minimum social protection floor for Sierra Leoneans. The Policy outlines oversight and coordination structures for social National Social Protection Policy 2018 protection and outlines 11 priority areas, including increasing access to education, health, employment, active labor market programs, and protection. The Act establishes NASSIT and a ‘social security scheme to provide a retirement and other benefits to meet the contingency needs of workers.’ The Act National Social Security and stipulates that it is compulsory for workers in the Insurance Trust (NASSIT) 2001 formal sector to be covered by the scheme and provides Act No. 5 voluntary membership for the self-employed. Benefits payable under this Act include old age pension and old age gratuity, retirement grant, invalidity pension, invalidity grant, survivors’ pension, and survivors’ grant. Digital Economy It leads the process of national transformation by Sierra Leone National Innovation harnessing the potential of science, technology, 2019 & Digital Strategy and innovation, conducting research, and fostering capacity development. The Act provides citizens and interested parties with The Right to Access Information 2013 unrestricted access to information held by both Act government and non-state entities. Youth employability This revised policy outlines strategies and actions to National Youth Policy 2020 promote youth development, including employment opportunities. Sierra Leone Human Capital Review 26 While not exclusively focused on youth, this policy aims National Employment Policy 2016 to improve overall employment prospects, which can benefit the youth as well. This policy encourages companies operating in Sierra Local Content Policy 2012 Leone to prioritize local hiring. Climate change The most recent NDC recognizes the impact of climate change on various aspects, such as health and Sierra Leone Nationally 2021 employment. For instance, it discusses the significance Determined Contribution (NDC) of implementing enhanced agricultural methods and improving healthcare delivery services. It includes adaptation actions in the healthcare sector National Climate Change Strategy 2021 and initiatives targeting young women, the youth, the and Action Plan elderly, and individuals with disabilities. Its mission is to engage all sectors of Sierra Leonean society, prioritizing vulnerable groups, in climate National Climate Change Policy 2012 change adaptation and mitigation. This aims to Framework (NCCPF) advance sustainable socio-economic development in the country. The NAPA established a connection with the Poverty National Adaptation Programme Reduction Strategy Paper (PRSP) goals, aiming to 2007 of Action (NAPA) enhance public health and biodiversity to contribute to sustainable development. It aims to pinpoint necessary actions for safeguarding National Environmental Action 2002 Sierra Leone’s environment, focusing on areas such as Plan environmental education and training. Source: Authors’ Research. 27 Chapter 2 - Enabling Environment for Human Capital 2.2 Government’s Main Actors Finance and governance. The Ministry of Finance (MoF), working in collaboration with the Ministry of Planning and Economic Development (MoPED), is in charge of managing the revenue and finances of the Government and ensures that activity costs in each sector in relevant ministries are accommodated in the national budget. The Ministry of Local Government and Community Affairs (MLGCA) is responsible for local government, which comprises 22 Local Councils. Local Councils have wide-ranging service delivery mandates in key essential services sectors, including primary and secondary health, basic education, agricultural extension services, water supply and sanitation, and administration of other devolved functions. Education. The education sector of Sierra Leone is managed by two ministries – the Ministry of Basic and Senior Secondary Education (MBSSE) and the Ministry of Technical and Higher Education (MTHE). The MBSSE is responsible for pre-primary, basic education, and senior secondary education. Teacher development and management is organized by a semi-autonomous body, the Teaching Service Commission (TSC), which is operated under the MBSSE and is responsible for teacher recruitment, quality development through training, and teacher deployment based on need. The MTHE oversees tertiary and vocational education. The two education ministries work closely with other education agencies, donors, and non-governmental organizations (NGOs) to improve the quality of education services. Health. The Ministry of Health and Sanitation (MoHS) is the Government’s agency responsible for delivering health care services in the public sector. The MoHS is in charge of policy, planning, management, and oversight of specific health programs and supporting and monitoring the work of the districts and other health sector areas in reproductive, maternal, neonatal, child, and adolescent health. It also supports and promotes coordination activities within the Ministry and with donors, NGOs, and the private sector. In addition, the National Secretariat for the Reduction of Teenage Pregnancy, embedded in the MoHS, spearheads the implementation of the national strategy for the reduction of adolescent pregnancy and child marriage and provides technical guidance to other actors implementing activities that are focusing on reducing teenage pregnancies and child marriage in Sierra Leone. The Government efforts on food security and nutrition are led by the MAFS and MoHS, along with other line ministries and stakeholders. The Ministry of Youth Affairs (MoYA) and the National Youth Commission (NAYCOM) mainly handle national youth affairs.The MoYA is responsible for developing policies and a legal framework relating to youth development, while the NAYCOM is the implementing entity with the objective of empowering the youth to develop their potential, creativity, and skills for national development and other related matters. In addition, various other ministries also support programs targeted to improve the capacity of the youth, such as the MTHE, the Ministry of Employment, Labor and Social Security (MELSS), the Ministry of Gender and Children’s Affairs (MGCA), and the Ministry of Agriculture and Food Security (MAFS). Social protection. This mainly comprises the following categories of programs: social insurance (which includes contributory pension plans); social assistance; labor market programs; and private transfers. They are led by the Ministry of Employment, Labor and Social Security (MELSS), the National Commission for Social Action (NaCSA), and other line ministries. Various ministries support early childhood development (ECD). The MoHS is mainly responsible for the earliest years of life (maternal and young child health and nutrition), and the MBSSE takes over the role in school-based early childhood education/preschool. While health and education ministries have the lead in coordinating ECD, other agencies also play a leading and coordinating role, including the private sector, NGOs, and social protection agencies. Cross-cutting areas such as gender, disability, and social inclusion. Cross-cutting areas such as gender, disability, and social inclusion are led by the Ministry of Gender and Children’s Affairs (MGCA) and the Ministry of Social Welfare (MSW), working closely with other line ministries. Sierra Leone Human Capital Review 28 The Government has taken a comprehensive approach to tackling complex human capital issues. As discussed above, various Government actors are working on human capital development in Sierra Leone. In addition to the Government, actors, donors, NGOs, and the private sector play essential roles in pushing the human capital agenda forward. Recognizing the holistic needs of human capital development and the variety of policies, settings, and services to meet these needs, the Government has taken steps to work holistically and think multi-sectorally in policy and program design and coordination. The Government has created the human capital focal points led by the MoF and composed of various ministries. They coordinate efforts in human capital development and promote synergy among ministries and multiple agencies. Multi-sectoral coordination with clear roles and responsibilities should be maintained to avoid inefficiencies and duplication and ensure effective and comprehensive service delivery in human capital development. Table 2.2 presents the Government’s main actors who play essential roles in human capital development. Table 2.2 Government Main Actors Government Agencies Role Finance and Economic Development Mandated to formulate and implement sound economic policies and public financial management, ensure efficient allocation of public resources Ministry of Finance (MoF) to promote stable economic growth and development in a stable macroeconomic environment. Ministry of Planning and Responsible for providing strategic direction to the state and coordinating Economic Development national development policy towards effective and sustainable socio- (MoPED) economic transformation and development of Sierra Leone. Governance and Decentralization Ministry of Local Responsible for implementing decentralization and local governance Government and reforms. Community Affairs (MLGCA) Education Ministry of Basic and Senior Responsible for developing policies and strategies for implementing all Secondary Education learning and teaching-related activities in the pre-primary, junior secondary, (MBSSE) and senior secondary levels of education. Ministry of Technical and Responsible for policy and direction of technical and tertiary institutions. Higher Education (MTHE) Teaching Service Responsible for teacher performance and professional development. Commission (TSC) National Commission for Government body responsible for assessing and awarding technical and Technical and Vocational vocational diplomas and certificates. Awards (NCTVA) Tertiary Education Responsible for approving and monitoring all tertiary courses and Commission (TEC) accreditation. 29 Chapter 2 - Enabling Environment for Human Capital Youth Affairs Ministry of Youth Affairs Responsible for developing policies and legal frameworks relating to youth (MoYA) development. National Youth Commission Responsible for empowering the youth to develop their potential, creativity, (NAYCOM) and skills for national development and other related matters. Health Ministry of Health and Responsible for providing affordable and quality health care to enable the Sanitation (MoHS) national population to attain and maintain a satisfactory level of health. Embedded in the MoHS, the Secretariat spearheads the implementation of National Secretariat for the national strategy for the reduction of adolescent pregnancy and child the Reduction of Teenage marriage and provides technical guidance to other actors implementing Pregnancy activities focusing on reducing teenage pregnancies and child marriage in Sierra Leone. Social Protection Ministry of Employment, Responsible for developing and administering employment, labor and social Labor and Social Security security policies, and providing social security. (MELSS) A semi-autonomous Government agency that operates under the Office of National Commission for the President and is the leading implementer of social protection programs Social Action (NaCSA) in Sierra Leone. NSPS operates within NaCSA and is responsible for coordinating and National Social Protection facilitating social protection programs. The secretariat also provides Secretariat (NSPS) technical support to other institutions implementing social protection programs. National Social Protection Inter-ministerial body that oversees and guides social protection in Sierra Inter-Agency Forum Leone. (NSPIAF) National Social Security and Insurance Trust Responsible for administering the National Pension Scheme. (NASSIT) Gender, Disability, Social Inclusion Ministry of Gender and Responsible for developing policies and legal frameworks relating to issues Children Affairs (MGCA) of women and children under the age of 18. The Ministry deals with vulnerable and underprivileged persons or families, Ministry of Social Welfare including young people, women, children, the elderly, and persons with (MSW) disabilities. It is responsible for developing and executing policies and programs that promote their welfare and safeguard their rights. Sierra Leone Human Capital Review 30 Food Security Responsible for developing and executing policies and strategies for the Ministry of Agriculture and agriculture sector and further advising on other matters relevant to Food Security (MAFS) agriculture. Data, Technology, and Innovation It sits in the Office of the President and is mandated to transform Sierra Leone into an innovation and entrepreneurship hub and support the Directorate of Science, Government to deliver on its national development plan effectively and Technology, and Innovation efficiently by promoting the use of science, technology, and innovation. The (DSTI) DSTI is part of the Human Capital Development Incubator, and both work at the heart of the Government’s plan to develop health, education, and agriculture for human capital development. Ministry of Information and The Ministry guides policy formulation and regulations for the Information, Communications Communication, and Technology (ICT) sector. In charge of efficient regulation across the telecommunications industry, National Communications ensuring equitable enforcement of rules to ensure seamless sector Authority (NatCA) operations that ultimately serve consumers’ interests. Source: Authors’ Research. 31 Chapter 2 - Enabling Environment for Human Capital 2.3 Government Financing of Human Capital Sierra Leone’s budget shows a strong commitment to human capital development (Figure 2.1). Key human capital sectors – education, health, and social protection – are ranked in the top five spending for Government function. Education is the largest spending sector over the five-year period of 2015–20, accounting for, on average, 16 percent of total executed expenditures, followed by the health sector with 6 percent. Education, health, and social protection account for about 28 percent of total Government expenditures, reflecting the Government’s human capital development priorities. Figure 2.1 Government Priority Sector by Expenditure, Five-Years Average (2015–2020), Share (%) Source: BOOST data. Note: Government’s expenditure categories were mapped with the ten Classification of Functions of Government to identify the largest spending functions. Despite the Government’s strong commitment to investing in human capital, its spending on human capital is low and insufficient when considering expenditure as a percentage of GDP. Figure 2.2 presents HCI scores and public expenditure on health and education as a percentage of GDP for various countries (details on HCI are discussed in Chapter 3). Sierra Leone spends very little on health and education. The country’s poor outcomes in human capital, as discussed in later chapters, reflect its low spending levels. Sustained public funding is critical for the growth and expansion of public services related to human capital. Figure 2.2 Public Spending Expenditure on Health and Education as Percentage of GDP and HCI Source: Authors’ calculation based on HCI Data and EdStats. Sierra Leone Human Capital Review 32 Spending on Education Although the Government education expenditure has increased, it still does not meet international standards. The Government education expenditure has increased in recent years in both nominal and real terms (Figure 2.3). In 2017, 13.5 percent of Government expenditures went toward the education sector. By 2020, the share of total Government expenditures toward education increased to 20 percent. Although this shows the Government’s strong commitment to investing in education, the Government’s education spending in 2020 represented only 2.8 percent of GDP. Compared to other low-income countries (where average government spending on education in 2018–2019 was 4.0 percent of GDP), the Government’s spending on education in Sierra Leone still fell below international standards (Figure 2.4). The Education 2030 Framework for Action suggests that countries allocate 4.0 to 6.0 percent of their GDP, ensuring countries are to achieve the Sustainable Development Goal (SDG) 4 on education. Figure 2.3 Trend of Public Education Expenditure Source: BOOST data. 33 Chapter 2 - Enabling Environment for Human Capital Figure 2.4 Public Spending on Education as Percentage of GDP and Percentage of Total Government Spending, an International Perspective Source: BOOST data for Sierra Leone, World Bank (forthcoming), World Bank EdStats for other countries. After introducing the Government’s flagship Free Quality School Education (FQSE) Program in 2018, the Government has shifted its focus and budget towards primary and secondary education (Figure 2.5). In 2019, 38 percent of total education expenditures were classified as expenditures on primary education. Public spending on the pre-primary sector has been substantially low (below 0.1 percent of total Government education expenditure). At the secondary level, expenditures have more than doubled between 2017 and 2019. In 2017, secondary education only accounted for 21 percent of total education expenditures, and this increased to 30 percent by 2019. Spending at the tertiary level declined from 29 percent to 21 percent between 2017 and 2019. Figure 2.5 Share of Education Spending by Level Source: BOOST data. Sierra Leone Human Capital Review 34 Under-investment in the capital education budget negatively affects the education system’s performance. The recurrent education budget includes personnel emoluments, goods and services, and current transfers (grants and subsidies). The capital education budget includes expenditures for construction, renovation, major repairs of buildings, and the purchase of heavy equipment or vehicles. In recent years, the Government has spent about 99 percent of total education expenditures on recurrent expenses. The extremely low capital budget contributes to poor school facilities and infrastructure (GoSL, 2020). The education sector has spent heavily on wages and salaries relative to goods and services and current transfers in the recurrent expenditure category. Between 2017 and 2019, 56 percent of total education expenditures went toward wages and salaries, while 44 percent went toward recurrent non-salary expenditures. Education resources on primary education are allocated towards meeting the needs of the poor. Figure 2.6 illustrates the results of benefit incidence analysis, which examines how governments allocate limited resources relative to income distribution. An expenditure pattern that is very close to the 45-degree line demonstrates perfect equality and represents parity across the five wealth quintiles of the population. Government spending on primary education in Sierra Leone is pro-poor since the concentration curve lies above the 45-degree line of perfect equality. In contrast, Government spending at secondary and higher education levels is unequal, with an extreme pro-rich bias in the allocation of resources for higher education. Figure 2.6 Equity in Public Spending on Education by Level of Education and Income Level Source: Authors’ calculation from BOOST Data and SLIHS. Spending on Health Domestic public financing for health has been increasing in Sierra Leone (Figure 2.7). In recent years, approximately 6 percent of public government expenditure has gone to the health sector. As discussed earlier, it ranks second among the top five spending single sectors, following the education sector. Before the COVID-19 pandemic, health spending in Sierra Leone was volatile and unpredictable, which complicated planning and informed decision-making. Annual variations have primarily been driven by the capital budget and salary payments. During the pandemic, spending on health increased significantly, driven by the creation of the National COVID-19 Emergency Response Centre (NACOVERC) (World Bank, 2021c). 35 Chapter 2 - Enabling Environment for Human Capital Figure 2.7 Government Public Spending on Health from Domestic Sources Source: Government data. As a share of GDP, Sierra Leone spends more than the Western Africa and low-income country averages, but health outcomes are lower (World Bank, 2021c). Government health spending accounted for about 5.7 percent of GDP, which is higher than the West African sub-regional average (4.9 percent), low-income countries average (5.3 percent), and Sub-Sahara Africa (SSA) regional average (5.1 percent), respectively. However, funding for the health sector remains insufficient. Available data shows that resources available to the health sector are well below National Health Sector Strategic Plan costs, suggesting that insufficient health financing is a barrier to fulfilling the country’s health strategy and improving health outcomes. Therefore, in addition to utilizing existing resources more efficiently, the country needs to increase overall health financing to meet international standards and fulfill the country’s health strategy. Given the current tight macro-fiscal situation in the country, this might be hard to achieve in the short term, but in the medium and long term, the Government should increase health spending. Recurrent expenditure accounts for 90 percent of public health expenditure. For the five-year period 2015– 2019, spending on recurrent and capital expenditures was New SLL 1.43 billion. Ninety percent (New SLL 1.28 billion) of the total was devoted to recurrent expenditure, while 10 percent (New SLL 147.71 billion) was spent on capital investments (Figure 2.8). The recurrent expenditure comprised personnel emoluments, goods and services, and current transfers (grants), while capital transfers and domestic capital spending comprised the capital expenditure. Figure 2.8 demonstrates the recurrent and capital expenditures for the same period. Low capital expenditure has led to inadequate availability of health infrastructure, which limits the delivery of quality health services. Sierra Leone Human Capital Review 36 Figure 2.8 Recurrent and Capital Health Expenditure, 2015–2019, New SLL Million Source: BOOST data and World Bank (2021c). Wages and salaries continue to dominate recurrent expenditures. Expenditure on salaries, wages, and other personnel emolument items for the review period is nearly four times (New SLL 902.87 million) the expenditure on goods and services (New SLL 227.64 million). Moreover, it is over six times the spending on current transfers (New SLL 137.21 million). Figure 2.9 shows trends in the critical components of recurrent expenditure. Higher expenditure on personnel emolument has crowded out spending for goods and services such as drugs and medical supplies. Figure 2.9 Composition of Recurrent Expenditures on Health Source: BOOST data and World Bank (2021c). Given the Government’s policy to focus on providing Universal Health Coverage (UHC), the share of public funding devoted to primary health care (PHC) needs to be increased. About 30 percent of the budget is allocated to the primary level of services for 2019–2021 (Figure 2.10). The Government’s priority is to prevent disease and respond to the comprehensive health needs of the population. Therefore, it is crucial to allocate the health budget in favor of PHC, focusing on achieving UHC. 37 Chapter 2 - Enabling Environment for Human Capital Figure 2.10 Budget by Health System Level, 2019–2021, US$ Million Source: World Bank, Global Financing Facility (GFF), and Government, Resource Mapping. While Government expenditure on public PHC services is pro-poor, Government health spending on public hospital services benefits richer groups. Figure 2.11 presents the distribution of health resources on different health services among various wealth quintile groups. The expenditure pattern for public PHC services (outpatient services) lies above the 45-degree line of perfect equality, meaning that public PHC services are pro-poor. However, Government health spending on public hospital inpatient and outpatient services is not allocated equally, benefiting the richer groups. Moreover, needs are concentrated among the poor, exacerbating these equity issues. Therefore, resources to public hospitals should be better targeted to ensure access to health care services by the poorer groups. Figure 2.11 Equity in Distribution of Health Service Benefits by Income Level Source: Authors’ calculation from government and SLIHS data. There are also regional gaps in resource allocation. Figure 2.12 shows per capita health expenditure by district. Those who live in Western Urban receive the highest per capital health expenditure, US$24, which is more than twice as high as the average expenditure for the other districts. Urban/rural disparities can also be seen in the deployment of health personnel and distribution of healthcare infrastructure to the detriment of people in rural areas (World Bank, 2021c). For example, the ratio of average health personnel Sierra Leone Human Capital Review 38 who regularly consulted patients in urban centers compared to rural communities was nearly five to one. Similarly, the average infrastructure index was 90 percent for urban facilities compared to 70 percent for rural facilities. This implies easy access to healthcare for those living in urban areas. On the other hand, the uneven distribution of health infrastructure denies essential healthcare access to people in rural areas, who depend heavily on public healthcare services. Figure 2.12 Per Capita Health Expenditure by District, 2019–2021, US$ Source: World Bank, Global Financing Facility (GFF), and Government, Resource Mapping. Spending on Social Protection Sierra Leone’s social assistance spending is relatively low (World Bank, 2021e). Social protection has become an increasingly important policy instrument in Sierra Leone, as highlighted in the MTNDP for 2019– 2023 and other policy documents. However, the country spends less than 1 percent of its GDP on social assistance programs (Figure 2.13). This is lower than the regional average (1.5 percent) and the average for its income group (1.3 percent) and varies across years. The composition of programs in total social assistance spending reflects the changing priorities of the Government. The spending pattern shifted from non-contributory health services to education support programs between 2015 and 2019. In 2018 and 2019, education support programs constituted the predominant share of social assistance spending. Outlays on the ‘other social assistance’ category were sizable in 2019, relative to earlier years. This is primarily driven by expenditures approximating New SLL 23 million on grants for fee subsidies to schools as part of the FQSE program launched in 2018. The share of social pensions (other cash transfers that support the elderly), food and in-kind transfers has remained negligible. Social assistance in Sierra Leone is heavily dependent on donor funding. For instance, in the cash transfer program, Ep Fet Po, the Government contributed 17 percent of the total program funds in 2019, while the World Bank contributed 83 percent. This program is the principal channel available for combating poverty while ensuring resilience to economic shocks for the extreme poor and vulnerable households. The country needs to increase domestic funding for large, core social assistance programs. Wages and salaries dominate social protection expenditures. In recent years, expenditure on non-salary and non-interest for social protection programs has stayed below 0.5 percent of total expenditures on social protection programs (World Bank, 2021e). 39 Chapter 2 - Enabling Environment for Human Capital Figure 2.13 Composition of Main Social Assistance Spending Over Time (% of GDP) Source: World Bank (2021e). In 2018, the coverage of households receiving any social assistance program was 18.6 percent of the population. Table 2.3 shows the coverage of social assistance benefits (share of individuals living in a household where at least one member receives the transfer out of the total population) for total social assistance and each component program. The three largest social assistance programs were free medicines, in-kind transfers – comprising non-contributory health services other than free medicines – other in-kind transfers, and cash transfers. These programs reached households accounting for 45 percent, 40 percent, and 17 percent of the population, respectively. In addition, entrepreneurship support in the form of microloans benefitted households representing a sizable 13 percent of the population. Sierra Leone compares well against low-income countries in providing social assistance coverage for the poor. Social assistance in Sierra Leone covered 22.7 percent of the poorest quintile in 2018 (Table 2.3), relative to the 18 percent share of other low-income countries. Some programs, such as cash transfers, are more progressively targeted than others (such as in-kind transfers or microloans). For instance, the coverage of the poorest quintile, the extremely poor, and the moderately poor by the Ep Fet Po program is higher – 5.3 percent, 5.4 percent, and 4.1 percent, respectively – relative to the population average of 3.2 percent, indicative of effective targeting. This is not the case for some other programs. The current composition of essential social assistance programs is weighted towards in-kind and categorical programs benefitting special groups such as students and entrepreneurs. Untargeted programs are inefficient in protecting the poor and their human capital. Improving the targeting and efficacy of social assistance is vital to addressing the fragmentation of spending across several small programs and consolidating some of these into bigger programs with better targeting and coverage. Sierra Leone Human Capital Review 40 Table 2.3 Key Social Assistance Program Coverage, Percentage Q1 Q5 Extreme Moderate Total Q2 Q3 Q4 Non-poor (Poorest) (Richest) Poor1 Poor All social assistance 18.6 22.7 21.1 17.7 15.5 12.0 23.6 20.3 15.7 programs Cash for 0.6 0.9 0.7 0.5 0.6 0.3 1.2 0.6 0.5 Work Food for 0.5 0.8 0.7 0.1 0.3 0.3 0.9 0.6 0.2 Work Medicines 8.3 11.0 7.1 7.0 8.8 6.2 11.2 8.2 7.6 Microloans 2.4 1.0 2.0 3.0 3.7 2.8 0.6 1.8 3.4 In-Kind 7.5 8.9 8.0 7.5 6.1 5.6 10.3 7.8 6.5 Transfers Others 0.1 0.3 0.2 - 0.1 - 0.5 0.1 0.1 Food 1.3 2.1 1.7 0.9 0.6 0.3 1.6 1.8 0.6 Cash 3.2 5.3 4.4 2.4 0.8 0.9 5.4 4.1 1.6 Transfers Source: World Bank (2021e). This chapter has presented the enabling environment for human capital in Sierra Leone. Analysis of resource allocation for human capital has identified cross-sectoral financial constraints to successful investment in human capital development. There are not enough resources devoted to education, health, and social protection sectors, which prevents them from fulfilling the country’s development strategies and improving human capital outcomes. Recommendations in the area of financing are as follows: (a) improving efficiency and effectiveness of spending on human capital; (b) reprioritizing spending with a focus on interventions that have proven effective and targeting the poor and vulnerable; (c) increasing domestic resource mobilization; (d) strengthening governance, accountability, and management systems; (e) strengthening monitoring and evaluation of resources against services provided; and (f) using data for decision-making. 1 Households are characterized as extremely poor if their total household consumption expenditure is below the food poverty line (defined as New SLL 2,125 per adult equivalent annually in SLIHS 2018); households are characterized as moderately poor if their total household consumption expenditure is below the regular poverty line (New SLL 3,921 per adult equivalent annually) but above the food poverty line (https://www.statistics.sl/images/StatisticsSL/Documents/SLIHS2018/Stats-SL-SLIHS-Report-2018_25Oct2019-Final-formatted-Version.pdf) 41 Chapter 2 - Enabling Environment for Human Capital Chapter 3 Human Capital Outcomes in Sierra Leone This chapter presents a detailed analysis of Sierra Leone’s HCI score and its underlying indicators. The analysis is structured according to the life-cycle approach with indicators presented for early years, childhood, adolescence/youth, working age, and productive aging with disaggregation where data allows. Photo: © Moses Alex Kargbo / World Bank 3.1 Overview of the Human Capital Index Global and Regional Comparisons The HCI measures the human capital a child born today can expect to attain by age 18, given the quality of education and healthcare in their country and the risks of poor health and poor education that prevail. The HCI thus measures the contribution of a country’s health and education system to the productivity of its next generation of workers. The World Bank determines a country’s HCI score using three key components: a) survival from birth to school age, measured using under-5 mortality rates; b) expected years of learning- adjusted school, measured using two indicators on the quantity and quality of available education, and c) health and nutrition, measured using the rate of stunting for children under-5 years old and the fraction of 15-year-olds that survive until age 60. Sierra Leone’s HCI score was 0.36 in 2020. This means that a child born in Sierra Leone will, on average, be 36 percent as productive when they grow up as they would have been if they enjoyed complete education and full health. Sierra Leone is foregoing enormous amounts of growth and development because of deficits in its health and education sectors, which are impairing the productivity of the next generation of workers. The significance of these deficits is shown in Figure 3.1, which shows that Sierra Leone is in the lowest quartile for four of the five components of the HCI, and ranks 165 out of the 174 countries included in the 2020 HCI, the latest period for which data is available (HCI, 2020). Figure 3.1 HCI 2020 and Components Source: HCI (2020). 43 Chapter 3 - Human Capital Outcomes in Sierra Leone Not only does Sierra Leone perform poorly globally, but Sierra Leone’s HCI score is lower than both the low- income country (LIC) and SSA averages (Table 3.1). Most notably, Sierra Leone lags far behind its regional and income-level counterparts in three of the six sub-components of the HCI: the probability of survival to age 5, harmonized test scores, and the adult survival rate from age 15 to 60. Table 3.1 HCI Components – Sierra Leone and Comparators Indicator Sierra Leone SSA LIC HCI Component 1: Survival Probability of Survival to Age 5 0.895 0.934 0.928 HCI Component 2: School Expected Years of School 9.6 8.3 7.6 Harmonized Test Scores 316 374 356 Learning-Adjusted Years of School 4.9 5 4.3 HCI Component 3: Health Survival Rate from Age 15 to 60 0.631 0.735 0.747 Fraction of Children Under-5 Not Stunted 0.705 0.688 0.654 Human Capital Index 2020 0.36 0.40 0.37 Source: HCI (2020). Recent Advancements in Human Capital Despite lagging behind some of its regional counterparts, Sierra Leone has made significant advancements in key human development indicators in recent years. For example, under-5 mortality, adult survival rates, and under-5 stunting prevalence have all improved markedly in Sierra Leone since 20052, while expected years of schooling increased from 9.2 to 9.6 years between 2017 and 2019, the two periods for which data is available (HCI, 2020). These national improvements do, however, mask sub-national variations, with advancements in human capital varying by both geographic and socio-economic factors, as shown in Figure 3.2, which disaggregates the overall HCI score by key socio-economic and geographical factors, revealing clear urban/rural, economic, regional, and demographic disparities. For example, HCI scores for the poorest quintiles are 10 percentage points lower than the richest, and in rural areas, HCI scores are seven percentage points lower than urban areas. Sierra Leone Human Capital Review 44 Figure 3.2 Human Capital Scores in Sierra Leone by Social, Economic, and Geographic Factors, 2020 Source: HCI (2020) for gender, UNICEF (2017) for all other disaggregation. Despite advancements in human capital in recent years, Sierra Leone faces many challenges, which could be exacerbated by its young and rapidly growing population. Like most countries in SSA, Sierra Leone has experienced a significant drop in mortality rates in recent years, which, when combined with the country’s high fertility rate – 4.2 births per female in 2019 – has led to a large youth bulge in the country, as shown in Figure 3.3 (DHS, 2019). As a result, 42 percent of the population is currently below the age of 15, and this growing young population is increasing demands for schooling, healthcare, and jobs in the country, stretching the already over-burdened services and the country’s small economy. Figure 3.3 Population Age Structure for Males and Females in 1990, 2019, and Forecasted for 2100 Source: Institute for Health Metrics and Evaluation [IHME] (2020d). 45 Chapter 3 - Human Capital Outcomes in Sierra Leone While the Government of Sierra Leone recognizes the potential of its young and dynamic population to drive the country forward, this potential can only be realized through significant investments in human capital. The demographic dividends refers to the economic growth that can be realized from shifts in a country’s age structure, as is set to happen in Sierra Leone due to the country’s significant youth bulge. The size of this dividend will be constrained if investments in the economy, and investments in the population, are insufficient. If Sierra Leone is to realize its demographic dividend, it must invest in the human capital of its population through improving access to quality education and healthcare. Human Capital Over the Life-Cycle Human capital formation is an unfolding and cumulative process, beginning in utero and expanding throughout the life-cycle. To explore the accumulation of human capital in Sierra Leone, this report examines key human capital indicators throughout a person’s lifetime. It begins by looking at the formative processes that influence human capital in utero before examining human capital accumulation throughout childhood, adolescence/youth, working age, and the productive aging population. Figure 3.4 shows how different stages of the life-cycle impact human capital accumulation. Figure 3.4 Components of the HCI Source: Author’s interpretation, based on World Bank (2022a). While this report is guided by a life-cycle approach, it also recognizes the critical importance of promoting gender equality to advance human capital. This is because improvements in female human capital benefit women and their children and can help prevent intergenerational cycles of inequality and poverty. Specific attention is therefore given in this report to factors that impair female human capital accumulation, such as child marriage, access to family planning, and high adolescent fertility rates, among others, which affect both women’s human capital and the human capital of their children. As shown in this report, disparities exist between several socio-groups for numerous human capital indicators (see Box 1). Therefore, understanding why certain sub-groups perform better than others and how this information can be leveraged to improve human capital accumulation across the country is paramount. 2Between 2005 and 2018, there was a notable rise in the likelihood of children surviving to age 5, increasing from 0.796 to 0.895. Additionally, from 2005 to 2019, there was an observed improvement in adult survival rates, which grew from 0.54 to 0.631, while the fraction of children under-5 not stunted rose from 0.55 to 0.705. Sierra Leone Human Capital Review 46 Box 1. Inequalities in Access to Healthcare Seventy-two percent of women aged 15–49 reported ‘serious problems in accessing healthcare’ in 2019, down from 87 percent in 2008 (DHS, 2008 and 2019). While this indicates marked improvement over this period, it is clear that significant challenges remain in advancing access to care in Sierra Leone. This study conducted a Human Opportunity Index (HOI) analysis to measure how key socio- economic characteristics affect access to healthcare for adult women and, by extension, their children in Sierra Leone. HOI analyses inequalities in access to calculate the contribution to inequality of the circumstances examined: the place of residence (urban/rural); district; wealth; and education. As can be seen in Figure B.1.1, access to healthcare is substantially influenced by both income (Asset Index Quintile) and location (urban/rural) in Sierra Leone. These two factors account for 70 percent of unequal access to healthcare in Sierra Leone. Figure B.1.1 Human Opportunities Index, Access to Healthcare Services Source: DHS (2019). This is particularly revealing as despite the country’s Free Health Care Initiative (FHCI, 2010), which is supposed to abolish essential healthcare fees for pregnant women, lactating mothers, and children under-5, income is the greatest contributing factor in inequality of access to services. Analysis of the SLIHS 2018 shows that 63 percent of women reported paying for antenatal care (ANC) in 2018, 64 percent for treatment for a sick child, and 10 percent reported paying to vaccinate children. While vaccinations are almost always provided for free or at low cost (median cost of 5,000 Leones), almost two-thirds of households pay for ANC and treatment for their children, with the median fees paid of 30,000 Leones for treatment of a sick child (around US$4 in 2018) and 10,000 Leones (just over US$1 in 2018) for the first ANC visit. These amounts are far from trivial for poor households and, as shown in Figure B1.1, appear to be creating barriers to access to healthcare. Furthermore, Figure B.1.1 shows that access to healthcare is not only influenced by income, but also by location. While the proportion of households with a health clinic within 30 minutes of their home increased from 22 percent in 2011 to 57 percent in 2018 (SLIHS, 2011 and 2018), these improvements were not universal. Changes in access have been almost identical across wealth quintiles and urban/rural locations, with disadvantaged groups not catching up with more advantaged households. Most notably, only 40 percent of households in rural areas have a clinic within 30 minutes of their home, compared to 76 percent in urban areas, with some districts particularly adversely affected (World Bank, 2020b). 47 Chapter 3 - Human Capital Outcomes in Sierra Leone 3.2 Fetal and Maternal Health During Pregnancy (in Utero) Maternal Health and Mortality Rates in Sierra Leone Maternal health is essential to the survival and well-being of both mother and infant. Maternal nutrition during pregnancy plays a pivotal role in fetal growth and development. Suboptimal maternal nutrition can lead to low birth weight, fetal intrauterine growth retardation, poor immune system development, and developmental delays for children, leading to heightened child morbidity and mortality (Belkacemi et al., 2010; Fall, 2013). Maternal mortality is a major public health issue in Sierra Leone. Figure 3.5 presents the maternal mortality ratio (MMR)3 for all SSA countries as of 2019. According to this map, Sierra Leone has the second highest MMR in SSA (and the world), behind only Liberia. However, despite the country’s persistently high MMR, significant progress has been made in recent years, with Sierra Leone’s MMR falling from 1,165 deaths per 100,000 live births in the seven years preceding the DHS 2013 survey, to an estimated 443 deaths per 100,000 live births in 2020, a fall of 62 percent (World Health Organization [WHO], 2023). Figure 3.5 MMR in Sub-Saharan Africa, 2019 Source: IHME (2020c). 3 The MMR is defined as the number of maternal deaths per 100,000 live births during a given time period. Sierra Leone Human Capital Review 48 Causes of Maternal Mortality in Sierra Leone Sierra Leone’s falling MMR4 has been driven, at least in part, by increases in the use of pre- and postnatal healthcare services and a rise in the number of assisted deliveries across the country (DHS, 2019). The number of women adhering to the recommended minimum of four ANC visits rose from 56 percent in the five years preceding the DHS (2008) to 79 percent in the five years preceding the DHS (2019), while 86 percent of mothers who gave birth from 2017–2019 had a postnatal check-up within two days of birth, up from 58 percent from 2008–2010 (DHS, 2008 and 2019). Furthermore, in the five years preceding the DHS 2019 survey, 87 percent of births were delivered by a skilled healthcare professional5, with 83 percent delivered in a health facility. This is a significant increase from the five years preceding the DHS 2008 survey, when only 25 percent of deliveries occurred in a health facility, and only 42 percent were assisted by a skilled professional6 (DHS, 2019). In fact, adherence to good ANC practices7, skilled assistance during delivery, and postnatal check-up rates were higher in Sierra Leone than in almost all SSA countries in 2019 (DHS, 2023). Despite recent progress, Sierra Leone’s MMR remains one of the highest in the world. This is largely due to the country’s high fertility rate, its prevalence of high-risk fertility behaviors8, and, most significantly, its poor quality of healthcare (DHS, 2019). Fertility behaviors have been shown to impact maternal and neonatal health outcomes significantly. However, while high-risk fertility behaviors in Sierra Leone are prevalent, the country has the joint lowest fertility rate and a similar prevalence of high-risk fertility behaviors compared to other West African countries (DHS, 2023). Furthermore, the proportion of births delivered by a skilled assistant is higher in Sierra Leone than in almost all other West African countries, yet these countries still have a lower MMR than Sierra Leone (DHS, 2023). Given the country’s relatively favorable fertility and maternal health behaviors, quality of care appears to be an important factor in Sierra Leone’s high maternal mortality rates. Quality of care is a significant issue in Sierra Leone. Data from the 2017 and 2019 Maternal Death Surveillance and Response reports show that the causes of maternal mortality in Sierra Leone are dominated by avoidable (i.e., preventable or treatable) conditions, such as post-partum hemorrhages (PPH), hypertension, and sepsis (GoSL, 2017; UNICEF, 2022; Carshon-Marsh et al., 2022). In fact, while diagnoses of PPH – the predominant cause of maternal mortality in Sierra Leone9 – are high at 92 percent, only 23 percent of clinicians provided the correct treatment for PPH, revealing ‘a critical disconnect in provider knowledge and follow-up’ (World Bank, 2018). Indicators from the Sierra Leone Service Availability and Readiness Assessment (SARA) Plus Survey (2017) also show the facility average for records of birth plans was only 4.2 percent. The SARA also found that only 10 percent of facilities have the capacity to conduct a blood test for anemia, and that only 5.1 percent of facilities screen for syphilis. It also found that the facility-wide average for two tetanus toxoid (TT) injections was just 67 percent, despite over 90 percent of facilities reporting TT as a routine component of ANC. In addition to poor quality of healthcare, maternal and neonatal mortality rates are affected by the inequitable distribution of health workers across the country, with the misallocation of maternal healthcare professionals being particularly acute. Where health workers are present, the quality of maternal healthcare is typically poor, with only 31 percent of clinicians assessed by the Service Delivery Health Survey adhering to clinical guidelines for managing maternal and neonatal complications, indicating a low level of knowledge. In addition, although compliance varies by district, low compliance rates exist across the country, with compliance exceeding 50 percent in only one district, Tonkolili (World Bank, 2018). Consultations held with MoHS officials and development partners in January 2023 further highlighted the issues surrounding 4 From 569 deaths per 100,000 live births in 2010 to 495 deaths per 100,000 live births in 2019 (IHME, 2019). 5 Skilled assistant classified as ‘doctor, nurse, midwife, and auxiliary nurse’. 6 Despite significant increases in health facility and assisted births in recent years, the use of these services varies by residence, district, and mother’s education, indicating inequality in access/use. 7 Four+ ANC visits and beginning ANC in the first trimester of pregnancy. 8 32 percent of households have four or more children, 25 percent have at least one short-birth interval, and 50 percent of 20–24 year olds give birth by age 20 (DHS, 2019). 9 32 percent of maternal mortalities in Sierra Leone are due to post-partum hemorrhages (World Bank, 2018). 49 Chapter 3 - Human Capital Outcomes in Sierra Leone the country’s poor quality of health personnel. Most notably, low levels of education among health staff and a lack of career progression and job security have led to a shortage of high-caliber health personnel, and the lack of a comprehensive workforce management strategy has led to an imbalance in the deployment of health workers across the country. Maternal Death Surveillance and Response (MDSR) Program With support from development partners, the Government established the Maternal Death Surveillance and Response (MDSR) program in July 2015. The MDSR system ensures that every maternal death in the national health system is investigated to understand the factors surrounding the death and to ensure that corrective measures are taken. The program developed guidelines and established national and local structures to investigate all maternal deaths nationwide. Since its establishment, monthly maternal death review meetings have been held at the district and national levels, although with tremendous challenges. Box 2. Low Quality of Healthcare in Sierra Leone Poor health infrastructures, a lack of medical equipment, low drug availability, and low-skilled and inequitably distributed staff have all contributed to Sierra Leone’s low healthcare quality. Most notably, there is an inadequate number of skilled health personnel in Sierra Leone, with just two skilled healthcare workers per 10,000 inhabitants, far below the WHO recommended minimum of 23 per 10,000 (World Bank, 2018). Furthermore, health workers are distributed inequitably, with rural areas remaining noticeably underserved. For example, only 29 percent of nurses and midwives and 2 percent of doctors work in rural areas, despite 57 percent of the country’s population residing there, as shown in Table B.2.1 (World Bank, 2018). Absentee rates are also high across the country, with 30 percent of health personnel absent during the 2018 Service Delivery Health Indicator (SDHI) survey (World Bank, 2018). Table B.2.1 Distribution of Health Cadres by Ownership and Location Sierra Public Private Indicator Urban Rural Leone facility facility Average health 6.4 5.9 11.9 13.2 3.4 staff per facility Doctors (%) 2% 61% 39% 98% 2% CHO/CHA (%) 9% 86% 14% 79% 21% Nurses/midwives (%) 89% 84% 16% 71% 29% Total 100% 84% 17% 73% 27% Source: World Bank (2018). Sierra Leone Human Capital Review 50 In addition to poor staff allocation, provider ability and knowledge is low, with only 45 percent of tracer conditions10 correctly diagnosed by healthcare staff, with accuracy higher in urban areas (51 percent) than rural (37 percent). However, accurate diagnosis does not necessarily mean correct treatment, with large discrepancies between diagnosis and treatment for many conditions. For instance, even though 90 percent of health providers correctly diagnosed pulmonary tuberculosis in the SDHI 2018, only 4 percent provided the correct treatment (World Bank, 2018). Poor health infrastructures, a lack of basic medical equipment, and low drug availability have also created large deficiencies in the health sector (World Bank, 2018). Three key infrastructures – piped or protected water, functioning flush toilets or latrines, and a reliable electricity source – were examined by the SDHI (World Bank, 2018). Less than half (48 percent) of health facilities had access to all three types of basic infrastructure (73 percent urban vs. 37 percent rural). However, this improved steadily with the level of the facility, from 38 percent in health posts to 75 percent in health centers, to 96 percent in hospitals. Furthermore, only 56 percent of the country’s healthcare facilities had priority drugs available, with availability higher in urban facilities (61 percent) than in rural facilities (54 percent). Essential medical equipment was also lacking, with essential equipment referring to a weighing scale, a stethoscope, a sphygmomanometer, a thermometer, a refrigerator, and additional sterilization equipment at the health center and hospital levels. Only 32 percent of health facilities in Sierra Leone met these minimum equipment requirements, with hospitals at 35 percent, health centers at 53 percent, and health posts at 26 percent (World Bank, 2018). In countries with high fertility rates, such as Sierra Leone, ensuring access to quality obstetric care (basic and comprehensive) is essential. Yet only 9.3 percent of health centers and 2 percent of health posts offer full basic emergency obstetric and neonatal care (BEmONC), and only 1.5 percent of all facilities are equipped to provide comprehensive emergency obstetric and neonatal care (CEmONC), as shown in Table B.2.2. Furthermore, only 3 percent of health posts and 11 percent of health centers had the capacity to conduct assisted vaginal deliveries in 2018 (World Bank, 2018). While Health posts are not designed to provide BEmONC services, Community Health Centers should offer CEmONC, yet only 9.3 percent of centers provide these services, inhibiting access to essential obstetric and neonatal healthcare services. 10 Tracer conditions are conditions presented to medical staff for assessment. The five conditions assessed were malaria with anemia, diarrhea with severe dehydration, pneumonia, pulmonary tuberculosis, and diabetes. 51 Chapter 3 - Human Capital Outcomes in Sierra Leone Table B.2.2 Availability of Basic and Comprehensive Emergency Obstetric and Neonatal Care Sierra Facility Freetown Urban Rural Public Private Leone Share of facilities offering full basic emergency obstetric care (%) All 4.8% 9.4% 13.9% 1.1% 3.9% 4.8% facilities Hospital 65.5% 85.7% 65.5% . 70.6% 65.6% Health center 9.3% 0% 9.3% . 9.8% 9.3% Health post 1.5% 0% 5.0% 1.1% 1.1% 1.5% Share of facilities offering full comprehensive emergency obstetric care (%) All facilities 1.6% 4.7% 5.5% 0% 0.8% 13.4% Hospital 42.7% 37.5% 42.7% . 52.9% 36.7% Source: World Bank (2018). Notes: (a) As in many SSA countries, CEmOC is only offered at the hospital level. (b) All percentage differences calculated are statistically significant at p<0.05 Nutritional Status of Pregnant and Lactating Women In Sierra Leone, both under- and over-nutrition affect women of childbearing age, with 7 percent of women aged 15–49 classed as ‘mildly, moderately or severely thin’, and 28 percent as ‘overweight or obese’11, with proportions similar between 5-year age groups (DHS, 2019). Compared to its West African neighbors, Sierra Leone has a relatively low proportion of under-nourished female adults. Only two of West Africa’s fourteen countries (Liberia and Ghana) having a lower proportion of their female adult population classed as undernourished (BMI12 <18.5), while the proportion of females classed as ‘overweight or obese’ in Sierra Leone on a par13 with all other West African countries (BMI>=25.0) (DHS, 2023). Forty-eight percent of women of childbearing age were also classified as anemic14 in 2019, with anemia levels even higher among pregnant and lactating women, at 57 percent and 53 percent, respectively15 (DHS, 2019). With anemia raising both the risk of postpartum hemorrhage and of premature birth and/or low birthweight, its high prevalence among pregnant and lactating women will have implications for both maternal and neonatal health outcomes (DHS, 2019). 11 6 percent of women age 15-49 were ‘mildly thin’, 1 percent ‘moderately or severely thin’, 19 percent ‘overweight’ and 7 percent ‘obese’. 12 BMI refers to the Body Mass Index. 13 Sierra Leone has an average prevalence of overweight and obese women at 27.8 percent – the median for West Africa. 14 1 percent severe anemia, 23 percent moderate anemia, 23 percent mild anemia. 15 For pregnant women, 1 percent severely anemic, 33 percent moderately anemic, 23 percent mildly anemic. For breastfeeding women, 2 percent are severely anemic, 27 percent moderately anemic, 24 percent mildly anemic. Sierra Leone Human Capital Review 52 Neonatal Health and Mortality in Sierra Leone The percentage of weighed live births below 2,500 grams (underweight) in Sierra Leone was 5.0 percent in 2019, lower than all other West African countries, as reported by USAID’s DHS program (DHS, 2023). There is little difference in birth weight by socio-economic characteristics in Sierra Leone. However, the prevalence of low birthweight does vary significantly by district, ranging from 9.3 percent in Koinadugu to 1.0 percent in Kono (DHS, 2019). Low birthweight (defined as less than 2,500 grams at birth) carries various health risks for children, including impaired immune function, increased risk of disease, and increased mortality. While the proportion of underweight children in Sierra Leone is low, Sierra Leone’s neonatal mortality rate (NNMR)16 is one of the highest in the world at 31 deaths per 1,000 live births in 2019 (DHS, 2019). Furthermore, Sierra Leone has the twelfth highest NNMR in the world (DHS, 2023), with neonatal disorders the main cause of under-5 mortality in the country, comprising 25 percent of all infant and child deaths, as shown in Figure 3.6 (IHME, 2020a). Unlike all other measures of infant and child mortality17, the NNMR in Sierra Leone is higher in urban areas, higher among better-educated households (secondary or higher), and marginally higher among wealthier households (top two quintiles) (DHS, 2019). The reasons for this are unclear but may relate to sample bias, with these population groups more likely to report neonatal deaths or live near facilities that are better at reporting mortalities. However, there does not seem to be a good clinical explanation for these differences. Figure 3.6 Top Five Causes of Under-5 Mortality in Sierra Leone Source: Author’s interpretation using IHME (2020a). 16 NNMR is the number of children that die before reaching 28 days of age, per 1,000 live births in a given year. 17 The post-natal mortality rate, infant mortality rate, child mortality rate, and the under-5 mortality rate are all lower among wealthier, better-educated, and urban households (DHS, 2019). 53 Chapter 3 - Human Capital Outcomes in Sierra Leone The Causes of Neonatal Mortality High-risk fertility behaviors and poor compliance with recommended maternal health practices are strongly associated with high neonatal mortality in Sierra Leone (Table 3.2). Most notably, the NNMR is 50 percent higher for those whose delivery is not assisted by a skilled health professional. While the impact of high-risk fertility and maternal health behaviors is significant in Sierra Leone, the prevalence of high-risk fertility behaviors in Sierra Leone is comparable to other West African countries. Compliance with recommended maternal health behaviors is higher in Sierra Leone than in the country’s regional counterparts. As with maternal mortality in Sierra Leone, the driving factor behind the country’s high NNMR appears to be its low quality of care. Table 3.2 Neonatal Mortality Rates (NNMR) by Key Health-seeking and Fertility Behaviors Condition NNMR Maternal health-seeking behaviours Less than four ANC visits 36.8 At least four ANC visits 21.4 Not delivered in health facility 37.3 Delivered in health facility 28.8 No skilled assistance during delivery 42.5 Skilled assistance during delivery 28.0 High-risk fertility behaviours Mother is an adolescent 34.1 Mother is not an adolescent 29.8 Mother is 40+ years old 52.4 Birth order second (second child) 22.7 Birth order sixth or more (sixth or higher child) 48.3 Source: Author’s interpretation using DHS (2019). Note: Skilled assistants are classified as ‘doctor, nurse, midwife, and auxiliary nurse.’ Unskilled assistant includes ‘traditional birth attendants, relatives, and others’ (DHS, 2019). In Sierra Leone, approximately 70 percent of neonatal mortalities are due to preterm births, intrapartum complications, and neonatal infections (IHME, 2020b; WHO, 2020a; JCRMNM, 2013; Lawn, Cousens, and Zupan, 2005). A study conducted by Pattinson et al. (2011) illustrates how different interventions have prevented global maternal, fetal, and neonatal mortality. It highlights that skilled care, basic emergency obstetric care, and comprehensive care are particularly crucial to save lives. Given that seven out of ten neonatal mortalities in Sierra Leone are caused by maternal conditions or are preventable through maternal treatment, improving the availability of quality obstetric care in Sierra Leone is paramount. Sierra Leone Human Capital Review 54 Box 1 examines inequalities in access to healthcare in Sierra Leone, with income and location found to have by far the most significant impacts on healthcare access and, by extension, outcomes. The conditions that cause maternal and neonatal mortality are often the same, as are the interventions to reduce them. Investments in healthcare quality, particularly in basic and comprehensive emergency maternal and neonatal obstetric care, are essential in Sierra Leone (World Bank, 2018). Improvements in health-seeking and reductions in high-risk fertility behaviors will also help to improve maternal and neonatal health outcomes in Sierra Leone, particularly for the most vulnerable groups, who typically pursue higher- risk fertility behaviors and have poorer access to quality healthcare. FHCI (2010), BPEHS (2010), RMNCAH&N (2023) In 2010, the Government introduced the Free Health Care Initiative (FHCI) to improve access to quality health services for the most vulnerable and to reduce the country’s high maternal and child mortality rates. The initiative’s main goal was to eliminate out-of-pocket expenses, improve access to quality health services and advance equity of coverage for pregnant women, lactating mothers, and children under-5. However, many households report paying for many health services covered by the FHCI (SLIHS, 2018), showing that implementation of this policy is weak. In the same year, the Basic Package of Essential Health Services (BPEHS) was developed and launched to serve as a framework and guiding document for service delivery in primary and secondary public health facilities. The BPEHS was revised in 2022 to follow the life-stages approach and take into account the specific needs of different demographics. Moreover, in order to further demonstrate the Government’s willingness to improve the health and well-being of women, adolescents, and children, the Government of Sierra Leone, through the Ministry of Health and Sanitation, developed the Reproductive, Maternal, New-born, Child, and Adolescent Health (RMNCAH) policy in 2018, designed to end preventable maternal, new- born, child and adolescent deaths. Since introducing these initiatives, some improvements have been observed, including increased service utilization and coverage in immunization, antenatal care, and facility deliveries. Framework for the Person-Centred Life Stages Approach to Health Service Delivery (2023) In 2023, the Government of Sierra Leone, through the leadership of the MoHS and support from development partners, developed and launched a costed framework for the Person- centred Life stages approach to health service delivery to improve access to quality healthcare services and health security for all stages of human life devoid of undue financial hardship. The Life stages approach aims to ensure person-centred holistic care, promote integration and collaboration across programs and partners, system-wide strengthening and investment in social determinants of health including water, sanitation, and agriculture. This develops a healthier and more productive population that can contribute to national social-economic development. The approach calls for a reorganization of Sierra Leone’s service delivery models around nine fundamental pillars anchored on strong leadership and coordination for an integrated approach to health service delivery. RMNCAH&N Strategy (2023), CSAP (2023) and Guidelines for the Integration of Elimination of Mother to Child Transmission (EMCT) of HIV and Pediatric HIV into RMNCAH&N and TB Programs in Sierra Leone 2023 Given the crucial need to improve maternal and child health outcomes, Sierra Leone developed and launched three strategic documents to align Reproductive, Maternal, New-born, Child and Adolescent Health and Nutrition (RMNCAH&N) service provision to the national priorities and improve equity and access to quality services for maternal and child health services. 55 Chapter 3 - Human Capital Outcomes in Sierra Leone In 2023, the MoHS revised and extended the 2017–2021 RMNCAH strategy to promote improved health outcomes for women, new-borns, children, and adolescents by adapting an integrated health service delivery to ensure no opportunities are missed in the implementation of the new RMNCAH&N strategy. The extension provides an avenue to amalgamate the Government’s emerging priorities and focus – particularly the child survival action plan, the every new-born action plan/ending preventable maternal mortality, and nutrition services – into one single document to enhance holistic RMNCAH&N service delivery. This new strategy is also aligned with the MoHS’s life course approach, which emphasizes the continuum of care approach to RNMCAH&N service delivery by prioritizing interventions for each stage of life. The Child Survival Action Plan (CSAP) aims to further reduce under-5 mortality to less than 71 per 1,000 live births by 2025 by refocusing efforts to abolish preventable child death. It adopts a holistic approach to child health interventions by focusing on the period 1–59 months, which accounts for about 70 percent of under-5 mortalities in Sierra Leone. It employs a collaborative approach to tackling issues to improve child health and survival by bringing together all relevant stakeholders across directorates and programs within the MoHS. Given the increase of mother-to-child transmission of HIV in Sierra Leone and the low availability of preventive services for mother-to-child transmission, Sierra Leone developed and launched guidelines for the Integration of Elimination of Mother-to-Child Transmission of HIV and Pediatric HIV into RMNCAH&N and TB programs in Sierra Leone. The guideline seeks to integrate the EMCT and Pediatric HIV into RMNCAH&N and TB programs, all of which aim to improve maternal and child health outcomes. In particular, the integration will increase efficiency in service delivery and promote the expansion of access and coverage to quality EMCT, Pediatric HIV, RMNCAH&N and TB services, thereby addressing multiple needs of clients and improving adherence to HIV services. 3.3 Infant and Child Mortality, Stunting, and Chronic Malnutrition Infant and Child Mortality Sierra Leone’s infant and child mortality rates are among the highest in the world. The country’s under-5 mortality rate stood at 122 deaths per 1,000 live births in 2015–2019, meaning that out of 100 children born in Sierra Leone today, only 88 are expected to survive to the age of 5 (DHS, 2019; Carshon-Marsh, 2022). This marks a slight improvement from the 140 deaths per 1,000 live births recorded in 2003–2008 (DHS, 2008, 2019), but still, Sierra Leone has the second highest under-5 mortality rate in West Africa behind Nigeria (DHS, 2023). The country’s infant mortality rate18 is the most significant driver of under-5 mortality, with 62 percent of all under-5 deaths occurring within the first year of life. As shown in Table 3.3 and Figure 3.7, mortality rates vary by socio-economic characteristics, with variations most significant by district. Under-5 mortality rates range from highs of 186 deaths per 1,000 live births in Port Loko to lows of 74 deaths per 1,000 live births in Bonthe (DHS, 2019). 18 The probability of dying between birth and the first birthday. Sierra Leone Human Capital Review 56 Figure 3.7 Under-5 Mortality (and Sub-Mortality) Rates by Location Source: DHS (2019). Excluding the country’s neonatal mortality rate (NNMR), which is discussed in the previous section, infant and child mortality rates19 are lower among wealthier, urban, and better-educated mothers (DHS, 2019). The poorest 60 percent of the population (bottom three quintiles) demonstrate similar levels of post-neonatal and infant mortality rates, while mortality rates are significantly lower among better-educated women. As in other countries, infant and child mortality rates are higher for boys than girls and higher among children born to mothers with primary or no education (Table 3.3) (DHS, 2023). Table 3.3 Infant and Child Mortality Rates – Socio-Economic Characteristics Characteristic NNMR PNNMR IMR CMR U5MR Gender Male 35.0 49.6 84.6 54.0 134.1 Female 25.9 40.0 65.9 46.7 109.5 Location Urban 34.2 33.2 67.4 42.9 107.5 Rural 28.5 51.1 79.6 54.4 129.7 Mother’s education No education 30.1 48.3 78.4 50.4 124.9 Primary 28.8 51.5 80.3 65.0 140.1 Secondary 31.6 37.5 69.1 46.1 112.0 Higher 37.0 10.4 47.4 13.3 60.1 Wealth quintile Poorest 30.1 52.4 82.5 60.0 137.5 Poor 30.9 47.6 78.5 45.4 120.3 Middle 29.4 49.1 78.5 53.2 127.6 Rich 31.1 39.6 70.7 51.0 118.1 Richest 31.4 29.9 61.3 38.4 97.3 Source: DHS (2019). 19 Post-neonatal mortality (the probability of dying between months 1–12), Infant mortality (the probability of dying between birth and the first birthday), Child mortality (the probability of dying between exact ages one and five), and Under-5 mortality (the probability of dying between birth and the fifth birthday). 57 Chapter 3 - Human Capital Outcomes in Sierra Leone Infant and Child Malnutrition Malnutrition refers to deficiencies, excesses, or imbalances in a person’s intake of energy and/or nutrients (WHO, 2015a). Wasting, an indicator of acute malnutrition, uses a weight-for-height ratio20 to determine malnutrition and is typically the result of inadequate food intake or recent illness (SLNNS, 2021). Stunting is a measure of chronic malnutrition calculated using a height-for-age ratio21. It reflects a failure to grow in stature due to poor nutrition, repeated infection, and/or inadequate psychosocial stimulation over a prolonged period (WHO, 2015b). Stunting in early life, particularly the first 1,000 days, can have significant adverse developmental consequences affecting a child throughout their lifetime. These include poor cognition, low educational performance, poor physical development, and an increased risk of contracting nutrition-related chronic and non-communicable diseases in later life (WHO, 2015a). From 2010 to 2019, the proportion of wasting among under-5s decreased from 8 percent to 5 percent in Sierra Leone, while over the same period, the prevalence of stunting fell from a national high of 44 percent to its current low of 30 percent (UNICEF, 2010; DHS, 2019). This dramatic drop in stunting prevalence means that Sierra Leone is now positioned just above halfway in the regional SSA distribution of under-5 stunting prevalence, despite having the fifth lowest GDP per capita in the region22, indicating above-expected performance (World Bank, 2022b). This large drop in stunting prevalence coincided with the implementation of the FHCI in 2010, which eliminated healthcare fees for pregnant women, lactating mothers, and children under-5. Within Sierra Leone, differences in stunting rates between urban and rural areas have remained largely constant, but differences by district have changed dramatically in recent years. Under-5 stunting prevalence was 8 percent higher in rural vs. urban areas in 2000 and 7 percent higher in rural vs. urban areas in 2019. Despite this consistency, changes between rural and urban districts have been significant, with district disparities shifting over time. Most notably, Western Area Rural had the highest under-5 stunting rate in 2010 but had the lowest under-5 stunting rate of all Sierra Leone’s districts as of 201923. The district with the lowest under-5 stunting rate in 2010 (Western Area Urban) now has the fourth highest (DHS, 2019)24. Sierra Leone Nutrition Policy (2012) Sierra Leone’s National Nutrition Policy provided a key step in addressing the nutrition challenges faced by the country. The aim of the policy is to improve the population’s nutritional status, with a particular focus on infants, young children, and pregnant and lactating women. More specifically, the objectives of the policy are to: (a) ensure that nutrition is prioritized on the political and national development agenda; (b) improve household food security situation to ensure that daily dietary population needs are met; (c) ensure appropriate feeding practices for children under-5 and women of reproductive age; (d) heighten preventive measures against malnutrition; (e) improve access to quality curative nutrition services; (f) promote evidence-based decision-making on food and nutrition issues; and (g) strengthen coordination amongst the various stakeholders involved in food and nutrition interventions in the country. 20 Children whose weight-for-height Z-score is below minus two standard deviations from the WHO’s child growth standards median are considered thin (wasted) (DHS, 2019). 21 A child is defined as stunted if their height is more than two standard deviations below the WHO’s child growth standards median (DHS, 2019). 22The fifth lowest of the 38 SSA countries that have comparable stunting data. 23 This may be partly explained by a 2015 pilot study that delivered Maternal, Infant and Young Child Nutrition training to Peripheral Health Units in 10 rural communities in the Western area. The results of this pilot, designed to improve counselling and sensitization among communities on stunting, its causes, and its reduction, may have led to the sharp fall in stunting rates in Western Area Rural. 24 In addition, under-5 stunting rates by gender and mother’s education have reduced roughly equally since 2005, but stunting rates by wealth quintile have been driven by convergence, with the poorest 60 percent of households closing the gap on the richest 20 percent (DHS, 2019). Sierra Leone Human Capital Review 58 The Causes of Infant and Child Mortality and Malnutrition in Sierra Leone High-risk fertility and poor maternal health-seeking behaviors were found to have a significant impact on neonatal mortality in Sierra Leone (see Section 3.2), and these same behaviors affect post-neonatal and child mortality rates as well (DHS, 2019). For example, birth intervals of less than two years, children born to mothers of high parity (more than three children), and the mother’s age (under 20 or over 40) all lead to higher post-neonatal and child mortality. In addition, ‘delivery in a health facility’ and ‘skilled assisted delivery’ reduce the probability of post-neonatal mortality by approximately 25 percent (DHS, 2019)25. While fertility and maternal health-seeking behaviors influence the PNNMR and CMR, these behaviors have a far greater impact on neonatal mortality, with the causes of mortality among children aged 1–59 months in Sierra Leone dominated by infectious diseases. The leading causes of mortality for those aged 1 month to 5 years (i.e., excluding neonatal mortality) are dominated by preventable and treatable causes, emphasizing the importance of improving healthcare quality and access, and preventative healthcare behaviors, such as safe infant and young child feeding practices, the use of Insecticide Treated Mosquito Nets (ITN), and child vaccinations, among others (Table 3.4). Table 3.4 Causes of Mortality among Those Aged 1–59 Months in Sierra Leone (Under-5s Excluding Neonatal Deaths) Causes of Post neonatal Child U5 excl. neonatal mortality (28–364 days) (1–4 years) (1–59 months) Malaria 24% 39% 31% Lower respiratory 24% 12% 18% infections Congenital birth 12% 5% 7% defects Diarrheal diseases 6% 5% 6% Meningitis 5% 4% 4% Other intestinal 2% 5% 4% infectious diseases Source: IHME (2020c). 25 If a skilled assistant is present at delivery, the PNNMR falls from 55 to 41 deaths per 1,000 live births; similarly, when a birth takes place in health facility the PNNMR falls from 55 to 40 deaths per 1,000 live births. 59 Chapter 3 - Human Capital Outcomes in Sierra Leone Access to Quality Health Care Services Low quality of healthcare contributes to the country’s high under-5 morbidity and mortality rates, with a lack of diagnostic accuracy for infectious diseases – the main cause of mortality among children under-5 – particularly significant. According to the World Bank (2018), just 16 percent of assessed health staff were able to identify the comorbidities of ‘malaria and anemia’ and 18 percent ‘of diarrhea with severe dehydration.’ With these comorbidities being significant causes of malnutrition and mortality in Sierra Leone (Bah et al., 2022), failure to diagnose these conditions is a significant concern. Furthermore, with preventable and curable infections constituting 70 percent of all mortalities among those aged 1–59 months26, there is a clear need to enhance diagnoses and treatment to improve recovery and reduce transmission and infection (IHME, 2020e). In addition, the lack of a dedicated program for child health, which is currently merged with the expanded program on immunization, may be diluting the focus and efforts on improving child health outcomes. Furthermore, access to healthcare facilities and treatment is far from universal in Sierra Leone, with household wealth and location (urban/rural) accounting for 70 percent of inequality in healthcare access. With the distance to health facilities far greater in rural areas at 3.3 miles compared to urban areas at 0.65 miles, and with healthcare costs as a proportion of income higher among rural households (see Box 1), these barriers may help explain why post-neonatal, infant, child, and under-5 mortality rates are higher in rural areas and among disadvantaged groups (World Bank, 2020b). National Healthcare Quality and Patient Safety Policy (2020) and Quality-of-Care Strategic Roadmap Sierra Leone has improved access to healthcare since the Free Health Care initiative launched in 2010, yet the country struggles to provide quality care in health service delivery. In 2020, the Government of Sierra Leone, through the MoHS, launched the National Healthcare Quality and Patient Safety Policy and Quality-of-Care Strategic Roadmap to provide guidance for service providers at all healthcare system levels. The policy aims to promote health improvement by implementing high-impact, evidence-based interventions and create an enabling environment for the effective delivery of quality healthcare at the various levels of care. The policy’s guiding principles surround Universal Health Coverage; Evidence-Based Interventions; Professionalism, Ethics, Dignity, Integrity; and Equity, with the roadmap emphasizing a continuum of care and a synergistic approach to service delivery. 26 These causes include vector-borne, water-borne, and enteric diseases where diagnosis and prompt treatment are essential for recovery and reducing transmission. Sierra Leone Human Capital Review 60 Malaria Prevention Health-seeking and preventative healthcare behaviors are key to reducing mortality and morbidity among under-5s in Sierra Leone. ITNs have been shown to reduce child mortality, parasite prevalence, and malaria episodes in users, with a recent cross-country study estimating that ITN use reduces the incidence of severe malaria episodes by, on average, 44 percent, and associated child mortality by 17 percent (Pryce et al., 2018). As of 2019, 68 percent of Sierra Leonean households have at least one ITN (74 percent rural vs. 60 percent urban), a marked increase from 37 percent in 2008 (37 percent in rural and urban areas). This is largely due to significant Government investment in malaria control. Investments include increasing the availability of diagnostic testing, free malaria treatment through the 2010 Free Health Care Initiative (FHCI), the mass distribution of ITNs, and the delivery of malaria awareness campaigns (DHS, 2019; WHO, 2016). As a result of such interventions, the number of children under-5 sleeping under a mosquito net rose from 26 percent in 2008 to 59 percent in 2019, with ITN use varying significantly by location (rural 63 percent vs. urban 51 percent) and by district (Figure 3.8) (DHS, 2019). Over this same period, the estimated malaria mortality rate (deaths per 100,000 population) fell from 205.6, CI [191.7, 219.7] in 2008 to 88.36, CI [74.99, 104.4] in 2019 (WHO, 2023). Figure 3.8 Proportion of Under-5s Sleeping Under an ITN by District Source: DHS (2019). Vaccinations While malaria intervention coverage is increasing, child vaccinations are going in the opposite direction, with the percentage of children aged 12–23 months who receive all basic vaccinations27 falling to 56 percent in 2019 from a high of 68 percent in 2013 (DHS, 2019, 2013). Vaccinations are almost always provided for free or at a low cost. Yet, basic vaccination rates averaged just 56 percent in 2019, with no sub-group having a higher vaccination rate than 71 percent28. This fall in vaccination rates can, in part, be explained by the huge health system shock that occurred between 2014 and 2016, when the Ebola epidemic saw health facilities prioritize the provision of resources to respond to the outbreak at the expense of other healthcare services, such as routine vaccinations, while fears of contamination led to a decline in confidence in healthcare services and reductions in use (Jalloh et al., 2022; Masresha et al., 2020). 27‘Basic’ vaccinations refer to the BCG vaccine, three doses of DPT and polio vaccines, and a single dose of the measles vaccine. 28The sub-groups examined include by gender, birth order, urban/rural, district, mother’s education and wealth. The sub-group with the highest vaccination rate was women with higher than secondary education (71 percent), while the district with the highest vaccination was Bo at 70 percent (DHS, 2019). 61 Chapter 3 - Human Capital Outcomes in Sierra Leone Childhood vaccinations prevent a wide range of diseases that can impair physical and cognitive development and cause death. Examining potential key socio-economic determinants of vaccination uptake reveals that the only statistically significant determinants of childhood vaccination are the mother’s education and region. The predicted probability29 of a child receiving all basic vaccinations is 68 percent for mothers with above secondary education and 57 percent otherwise. Vaccination rates vary by region, with a predicted probability of 66 percent in the Southern region, 61 percent in the Eastern region, 53 percent in the Northern and Western regions, and 48 percent in the Northwest region (UNICEF, 2017). Differences by age and gender of household head, location (urban/rural), wealth index, and ethnicity are marginal and statistically insignificant. Water, Sanitation, and Hygiene (WASH) Practices Safe drinking-water and improved sanitation and hygiene are prerequisites for good health, with poor WASH practices significantly impacting child morbidity and mortality. While WASH access has improved significantly in Sierra Leone (Figure 3.9), just two-thirds of households had access to an improved water source30 in 2019, with Sierra Leone having the second lowest access rate in West Africa, behind Niger at 56 percent (DHS, 2023). Analysis of the DHS (2019) conducted for this report confirms the importance of good WASH practices in Sierra Leone, with stunting rates among children under-5 being 26 percent higher in households that use unprotected drinking water sources versus those that use protected water sources; 48 percent higher in households that have no dedicated area for hand washing compared to those that do; and 38 percent higher in households that use shared sanitation facilities, compared to those with sanitation facilities in the household’s dwelling. Only 6 percent of households in Sierra Leone have a dedicated hand WASH facility; 8 percent of households have a toilet facility in their own dwelling; and 16 percent of households have access to improved sanitation facilities that are not shared with other households (DHS, 2019). In light of these data, significant improvements to both malnutrition and mortality among under-5s could be realized through investments in safe WASH facilities and interventions to improve hand-washing practices (SLNSS, 2021). Figure 3.9 Access to Improved Water and Sanitation Facilities Source: DHS (2019). 29In the logistic regression modelling, a predictive probability is the odds that the dependent variable takes a specific value when one independent variable value changes while all other independent variables are held fixed. In this instance it refers to the probability a child will be vaccinated if the mother has secondary education. 30Improved sources of drinking water include piped water, public taps, standpipes, tube wells, boreholes, protected dug wells and springs, water from a tanker truck or cart, and bottled water (DHS, 2019). Sierra Leone Human Capital Review 62 Food Security and Dietary Diversity Food security, meal frequency, and dietary diversity significantly affect infant and child survival and nutritional status. According to DHS (2019), more than two-thirds of children aged 6–23 months were not meeting their minimum meal frequency, and three-quarters were not receiving an adequately diversified diet, with poor monotonous diets reported in all districts but particularly prevalent in Koinadugu, Falaba, Port Loko, Bonthe and Pujehun (SLNNS, 2021). While 54 percent of children under 6 months were exclusively breastfed in 2019, the percentage exclusively breastfeeding falls from 77 percent among those age 0–1 month to 28 percent among those age 4–5 months (DHS, 2019). Adhering to optimal Infant and Young Child Feeding (IYCF) practices is an integral part of ensuring adequate meal frequency and dietary diversity. These practices lay the foundations for child development and are essential for children to achieve their growth and development potential. The WHO recommends three IYCF practices for all mothers: early initiation of breastfeeding within one hour of birth; exclusive breastfeeding for the first 6 months of life; and the introduction of nutritionally adequate and safe complementary (solid) foods at 6 months, together with continued breastfeeding up to 2 years of age or beyond (WHO, 2021). Complementary feeding practices are introduced too early in Sierra Leone, with adverse effects on breast milk output and increased mortality risk due to infection (see Figure 3.10) (SLNNS, 2021). Figure 3.10 Breastfeeding Status of Children Under 2 Years Source: Author’s interpretations using DHS (2019). 63 Chapter 3 - Human Capital Outcomes in Sierra Leone Photo © Dominic Chavez/World Bank The predicted probability of being stunted is 17 percent for children under 6 months if exclusively breastfed, compared to 25 percent for those not exclusively breastfed and 33 percent for those never breastfed31 (DHS, 2019). As these results show, inadequate breastfeeding practices can significantly affect infant and child nutrition in Sierra Leone. Analysis of DHS (2019) shows that the richest and most educated mothers are least likely to initiate early breastfeeding practices and least likely to conduct exclusive breastfeeding32, putting their children at increased risk. The low prevalence of exclusive breastfeeding practices among wealthier and better-educated women may be due to their heightened employability, with maternity leave in Sierra Leone far shorter than the six-month exclusive breastfeeding period, meaning that many working women have to use alternative feeding practices. With the Parliament of Sierra Leone only passing a bill to regulate the marketing of breastmilk substitutes in 2021, these mothers could have been influenced by infant formula manufacturing companies that promote artificial feeding practices. The impacts of poor IYCF practices are significant not only for child malnutrition but also for child mortality. A meta-analysis from Sankar et al. (2015) suggests that infants who consume complementary solid foods before 6 months are almost three times more likely to die than exclusively breastfed infants. In Sierra Leone, complementary foods are introduced to many children prematurely (approximately 37 percent) (DHS, 2019), posing significant risks. 31Furthermore, for children under 6 months that are fed complementary foods (solids) during their first 6 months, the predicted probability of being stunted is 26 percent (DHS, 2019). 32Non-exclusive breastfeeding (for the first 6 months of life) was 59 percent for mothers with higher education or that completed secondary education, compared to 46 percent for all other education levels. While failure to adopt early initiation of breastfeeding was 5.8 percent for children whose mothers completed secondary or higher education compared to 2.8 percent for the rest of the population. Sierra Leone Human Capital Review 64 3.4 School-Based Education Early Childhood Education (ECE) Early childhood is a critical window of opportunity for human development since more than 80 percent of brain development occurs by the time a child is 5 years old. (Shonkoff and Phillips, 2000). Appropriate stimulation and early learning opportunities can help develop a person’s social-emotional and cognitive skills. ECE participation is low and ECD delay is a major issue in Sierra Leone. As reflected in the ECD index, in Sierra Leone 51.4 percent of children ages 36 to 59 months are developmentally on track in at least three of the following four domains: literacy–numeracy, learning, physical, and socio-emotional. However, children fare much better when it comes to physical development (90.2 percent) as compared to socio-emotional development (59.7 percent) and literacy–numeracy (15.4 percent) (Figure 3.11). These figures are not surprising given the low levels of participation in ECE. Only 12 percent of children aged 36 to 59 months participate in ECE, and only 13 percent of children are ready for primary school (Figure 3.12). While there is little difference in ECE participation and school readiness for girls and boys, there are significant differences for children residing in urban and rural areas. In rural areas, ECE participation and school readiness are at 3 and 4 percent, respectively, while in urban areas, the corresponding figures are 26 and 30 percent (UNICEF, 2017). Figure 3.11 ECD Index Composition Source: MICS 2010 and 2017 report (UNICEF, 2010 and 2017). 65 Chapter 3 - Human Capital Outcomes in Sierra Leone Figure 3.12 ECE Participation and School Readiness (%) Source: MICS 2010 and 2017 report. (UNICEF, 2010 and 2017). Note: ECE participation is defined as the ‘percentage of children ages 36–59 months attending early childhood education’. School readiness is defined as the ‘percentage of children attending the first grade of primary school who attended early childhood education program during the previous school year.’ National Policy on Integrated ECD, 2021 The MBSSE developed the National Policy on Integrated ECD in 2021. The policy provides an overarching framework with a shared vision, mission, goals, and objectives for delivering holistic ECD interventions and services for all children ages 0 to 8 years. In Sierra Leone, ECE services are largely provided by non-Government entities. Most pre-primary schools are run by missionary/religious groups or private individuals/groups, while the provision of Government schools is small. The largest provider is the missionary or religious groups (42 percent), followed by private individuals/groups (35 percent). Government pre-primary schools comprise only 10 percent of total schools. The policy acknowledges a role for non-Government providers and addresses the importance of mechanisms for regulation or quality assurance in the oversight of service delivery. Sierra Leone Human Capital Review 66 General Education Ensuring children stay in school and have access to quality education is critical to human capital formation. Over the past two decades, Sierra Leone has gradually improved its access to basic education. At the primary level, the education system is over capacity. It needs to focus on running more efficiently (e.g., age-appropriate entry and progression), and at the junior and senior secondary levels there is significant scope to improve access to school. In 2018, gross enrollment rates (GER) were 114 percent at the primary level, 81 percent at the junior secondary level, and 72 percent at the senior secondary level. The gap between primary GER and net enrollment rate (NER) has reduced between 2003 and 2018, showing improvement in efficiency (due to fewer overage students and less repetition). During the same period, GERs increased significantly at the junior and senior secondary school levels (28 and 35 percentage points, respectively) (Figure 3.13). Figure 3.13 GERs and NERs in Primary, Junior Secondary, and Senior Secondary School, 2003 and 2018 a.GERs b.NERs Source: Statistics derived from SLIHS 2003 and 2018. 67 Chapter 3 - Human Capital Outcomes in Sierra Leone Box 3. Impact of FQSE Policy on Enrollment and its Financial Implication The Government launched its flagship Free Quality School Education (FQSE) Program in 2018 to operationalize its vision for education – to ensure free quality education to all school-age children from primary to secondary school. The key elements of the program include (a) reducing barriers to accessing education (Government payment of public examination fees and per pupil subsidies in Government and Government-assisted schools); and (b) providing essential elements for quality education provision (policies to motivate teachers, provision of textbooks in core subjects, and teaching–learning materials). The education system has expanded quickly, especially with the inception of the FQSE Program. Despite the internal conflict, economic crisis, Ebola, and the COVID-19 pandemic, the number of students in the basic and senior secondary system has increased almost by 70 percent in the last decade, from 1,584,386 in 2010/11 to 2,689,953 in 2020. The number of learners increased in all sectors of education over time. This enrollment trend can be expected to continue in the coming years, especially for primary and secondary schools. There will be an increased number of Government-approved schools in the education system, which adds additional financial stress to the Government education budget. Figure B.3.1 Historical Evolution of Pre-Primary to Senior Secondary School Enrollment, 2010–2020 Source: MTNDP 2019 and annual school census (ASC) various years. Note: No data was available for 2014 due to the Ebola epidemic. Despite a substantial increase in school enrollment in recent years, further work is needed to enroll all out- of-school children (OOSC) and retain them in school. Approximately one out of every five children is out of school. While the percentage of OOSC has decreased between 2003 and 2018 for both the 6 to 11-year-old and 12 to 17-year-old age cohorts, the figures are high: 19 percent of children between the ages of 6 to 11, and 22 percent of children between the ages of 12 to 17, are out of school (Figure 3.14). Among those who enroll in school, it is estimated that one child in five leaves before completing the primary level (GoSL, 2020). Sierra Leone Human Capital Review 68 Figure 3.14 Share of OOSC Source: Statistics derived from SLIHS 2003 and 2018. There is inequality in access to education. While the urban–rural gap in enrollment has narrowed at the primary level, it has widened at the junior and senior secondary levels. Enrollment outcomes for females are better than for males across all school levels. The urban–rural gap in NERs at the primary level has narrowed from 20 percentage points in 2003 to 10 percentage points in 2018. However, at the junior secondary level, the gap has increased from 15 percentage points to 24 percentage points, while at the senior secondary level, the gap has increased from 12 percentage points to 23 percentage points. This indicates (among other factors) the lack of adequate numbers of junior and senior secondary schools in rural areas in Sierra Leone. The latest reported NERs for girls at the primary, junior, and senior secondary levels are 81, 31, and 17 percent, respectively, while for boys, the corresponding figures are 78, 27, and 15 percent. For the children in the poorest two wealth quintiles, while GERs at the primary level have stayed at the same level between 2003 and 2018, GERs at the junior and secondary levels have doubled and more than tripled, respectively, during the same period (Figure 3.15). Figure 3.15 GERs by Economic Status Source: SLIHS 2011 and 2018. Note: The poor are defined as the poorest 40 percent in income proxy (per capita expenditure). 69 Chapter 3 - Human Capital Outcomes in Sierra Leone There are numerous reasons for children not attending school. There is some information from parents of OOSC that predates the introduction of the FQSE policy, which reports that almost two-thirds of parents surveyed did not value the education their children would receive (SLIHS, 2018). This could be attributed to various factors, including the poor quality and relevance of education and slow progress (e.g., in some parts of the country, up to 20 percent of primary school children are repeating a grade). Twenty-three percent of parents of OOSC cited financial constraints to sending their children to school. This is reinforced by the findings of Samonova et al. (2021), which show that despite the FQSE policy, parents still incur large costs in sending their children to school, particularly those sending their children to unapproved schools. Physical access to schools (particularly primary schools) was not reported as a major constraint in sending children to school. Only 5 percent of surveyed parents indicated that their child is out of school because the school is too far (GoSL, 2020). Box 4. Low Levels of School Participation Explained by Women in Sierra Leone Several themes emerged from in-country HCR consultations with girls and young women explaining low levels of school participation: • High levels of poverty make education unaffordable. Abject poverty in so many homes and communities results in challenges for parents to provide basic necessities such as uniforms, lunch money, and transport fares to get to school, coupled with the need to send children to work in farms, markets, mines, or have them look after younger children in the household. The FQSE Program abolished school fees, but these costs burden many households. • Parents’ perceptions that schooling is not learning. Throughout the girls’ school life, there are concerns in many communities that attendance in school will not result in girls getting educated. As a result, their attendance is not prioritized, even if they are enrolled. • High-stakes exams and repetition lead to dropouts. Public exams are a barrier when children are not taught well enough to pass to the next level. Many children get stuck repeating grades and, in particular, repeating exam classes. They may drop out at the first failure, or they may drop out after a few attempts; however, with no strategic remediation approaches in place, repetition becomes a significant cause of drop out, with teachers blaming the children and parents and generally failing to take responsibility for addressing their contribution to the issue. • Abuse and harassment. The acceptance of sexual abuse and harassment as norms were cited as considerable challenges for large numbers of girls in schools and results in their dropping out before completion. • Social norms. Girls spoke of the risk of being forced to join secret societies, and once circumcised, the pressure to marry increases, with many parents believing that girls that stay in school would bring disgrace to the family by getting pregnant before marriage. • Lack of self-belief. Participants mentioned that girls’ lack of self-belief in their intellectual and academic abilities contributed to not enrolling/persisting in school. This is further reinforced as these girls may not be exposed to female role models who can debunk these misconceptions. • Early pregnancy. The poor sex education and reproductive health services they receive increase the risk of early pregnancy, significantly contributing to poor school completion rates for girls. Sierra Leone Human Capital Review 70 Learning Outcomes Children lack basic foundational literacy and numeracy skills. Students in Sierra Leone scored 316 on a harmonized test score in HCI 2020, where 625 represents advanced attainment, and 300 represents minimum attainment. Results from early grade assessments in grades 2 and 4 reflect that the average percentage of correct answers is only 0.5 percent in reading at both grades 2 and 4 (Figure 3.16). Children fare better in numeracy than in reading: at grade 2 and grade 4 levels, students were able to answer 45 and 42 percent of questions related to addition correctly, respectively. In subtraction, students at the grade 2 level could only answer 27 percent of questions correctly, and the corresponding figure at the grade 4 level was 28 percent. A high percentage of students did not answer a single problem correctly: 73 percent of grade 2 students and 62 percent of grade 4 students had a literacy (reading comprehension) score of zero and 58 percent of grade 2 students and 53 percent of grade 4 students had zero scores in numeracy (subtraction). According to the Global Education Policy Dashboard, in 2022 only 3.2 percent of children achieve basic proficiency in math and language by end of primary while 95.8 percent of children aged 10, who are out-of- school or in-school, are not achieving basic proficiency on reading. Figure 3.16 Results of Reading and Numeracy Test in Grades 2 and 4, 2021 Source: SLIHS 2011 and 2018. Boys outperform girls at the primary level. Regarding sex-based differences in learning, at grade 2, boys and girls are approximately at par in reading comprehension (1 percent and 0 percent, respectively), while in numeracy, boys perform better than girls (in addition 49 percent, compared to 42 percent, respectively). Similar trends are observed at the grade 4 level, with boys and girls scoring only 4 percent on reading comprehension, while boys outperform girls in addition (85 percent and 78 percent, respectively) and subtraction (68 percent and 58 percent, respectively) (Table 3.5). 71 Chapter 3 - Human Capital Outcomes in Sierra Leone Table 3.5 Gender Difference in Learning Grade 2 Panel A: Grade 2  Boys  Girls  Difference  Reading 1%  0%  0%  comprehension  Numeracy 49%  41%  7%***  addition  Numeracy 29%  25%  4%**  subtraction  Grade 4   Panel B: Grade 4 Boys  Girls  Difference  Reading 2%  2%  0%  comprehension  Numeracy 85%  78%  7%***  addition  Numeracy 68%  58%  10%**  subtraction  Source: EGRA and EGMA, 2021. Note: *** Statistically significant at 1%, ** Statistically significant at 5%, *Statistically significant at 10%. Children’s lack of basic foundational literacy and numeracy skills is more acute in rural areas. According to MICS 2017, the urban–rural gap in literacy and numeracy skills is quite pronounced. In urban areas, 30 percent of children possessed foundational reading skills, and 22 percent of children possessed numeracy skills in 2017 compared to only 5 percent of children demonstrating literacy and numeracy skills in rural areas. In geography, the share of children possessing foundational reading skills was less than 10 percent in districts Pujehun, Kailahun, Moyamba, Tonkolili, Bonthe, Koinadugu, and Port Loko. Children from poor households are less likely to demonstrate foundational literacy and numeracy skills (Figure 3.17). Thirty-nine percent of children ages 7 to 14 in the richest wealth quintile demonstrate foundational literacy skills compared to only 3 percent of children in the poorest wealth quintile. Similarly, one-quarter of children in the richest quintile possess basic numeracy skills, while only 3 percent of children in the poorest wealth quintile possess basic numeracy skills. There are also differences by sex: in quintiles two, three, and four, boys are more likely than girls to possess basic literacy and numeracy skills. While there is parity in literacy between boys and girls for the richest wealth quintile, the gap remains in numeracy, with the share of boys demonstrating basic numeracy skills being 4 percentage points higher than the proportion of girls. Sierra Leone Human Capital Review 72 Figure 3.17 Percentage of Children Ages 7–14 Demonstrating Basic Literacy and Numeracy Skills by Wealth Quintile, 2017 Source: MICS 2017. Note: ‘Q’ denotes quintile, with Q1 as the poorest wealth quintile and Q5 as the richest quintile. Secondary students are behind in grade levels in terms of their learning. In 2017, only 11 percent of junior secondary school (JSS) 2 students were rated as learning at grade level (as prescribed in the curriculum) or higher in the math assessment, and by 2019 this number was only 3 percent (Figure 3.18). Similarly, in English 23 percent of JSS 2 students were performing at grade level in 2017 as compared to only 15 percent of students in 2019. Most JSS 2 students are at the primary grade 6 level of competency in math and English. For senior secondary school (SSS) 2 students, only 5 percent and 1 percent performed at the JSS 3 level or higher in English and math, respectively. At the primary level or below, 46 percent and 60 percent of SSS students are achieving in English and math, respectively. The Leh Wi Lan – Sierra Leone Secondary Education Improvement Programme annual review reports progress in learning outcomes through improved performance in the West African Senior School Certificate Examination (WASSCE) and the Basic Education Certificate Examination (BECE) exam (UK-FCDO, 2021). For instance, from 2019 to 2020, scores have improved from 5.01 percent to 6.8 percent in math and from 3.75 percent to 8.2 percent in English for the WASSCE. Figure 3.18 Junior Secondary School 2 Student Achievement, 2017–2019 Source: MBSSE (2017, 2018, and 2019). 73 Chapter 3 - Human Capital Outcomes in Sierra Leone School-level factors matter more than district-level factors when it comes to learning, yet most variation in learning is due to student-level factors. Table 3.6 decomposes the variation in student learning outcomes into three levels (district, school, and student level). The largest share of variance in learning outcomes is explained at the student level, which suggests student background, effort, and ability are very important when it comes to learning. When it comes to numeracy outcomes, the relative importance of school-level factors is more apparent as compared to reading outcomes. In terms of school-level factors, the language used at school is seemingly correlated with the literacy and numeracy scores, as shown in Figure 3.19. However, what matters is the language spoken at home. English-speaking students have the highest literacy score if they attend an English-language school. For numeracy, English-speaking students have higher scores if they attend an English-language school (Figure 3.20).   Table 3.6 Level of Variation of Learning at School and District Grade 2 Grade 4 Level of variation  Reading  Addition Subtraction  Reading  Addition Subtraction ICC  School  0.030  0.177  0.164  0.000  0.093  0.067     District  0.000  0.034  0.018  0.000  0.012  0.006  Std.  School  0.012  0.189  0.170  0.000  0.141  0.111     District  0.000  0.093  0.060  0.000  0.054  0.035  Residual    (Student 0.069  0.453  0.408  0.069  0.471  0.436  level) Constant     0.005  0.458  0.276  0.005  0.426  0.287  Source: Authors’ calculation based on EGRA and EGMA 2021.  Note: ICC=Intra Class Correlation and Std.= Standard Errors Figure 3.19 Learning by Language Spoken at School Source: Authors’ calculation based on EGRA and EGMA 2021. Sierra Leone Human Capital Review 74 Figure 3.20 Learning by Language Spoken at School and Home Source: Authors’ calculation based on EGRA and EGMA 2021. After controlling for school-level factors, there are differences in learning outcomes for boys and girls, and child engagement in learning activities at home is correlated with higher learning outcomes. Controlling for all other school-level characteristics (that is, school-fixed effects), it is apparent that for literacy, no student-level factors in the analysis in Figure 3.21 were correlated with literacy except for gender at the grade 4 level (with girls outperforming boys in reading). For numeracy, gender (with girls performing worse than boys), bringing textbooks home, and reading at home were all correlated with both the ability to do addition and subtraction. 75 Chapter 3 - Human Capital Outcomes in Sierra Leone Figure 3.21 Student-Level Factors Related to Learning Source: Authors’ calculation based on EGRA and EGMA 2021. Parents cite various educational challenges, including lack of teaching and learning materials, poor school infrastructure, and poor teaching and behavior of school staff. Twenty-eight percent of parents surveyed as part of the Service Delivery Index exercise conducted in 2020 cited a lack of access to textbooks and teaching and learning materials as a major challenge, followed by 27 percent of parents who cited poor quality of school infrastructure and WASH facilities. Also, 14 percent of parents cited concerns about poor teaching quality and school staff behavior as a major challenge (IGR, 2021). Sierra Leone Human Capital Review 76 Box 5. Poor Learning Outcomes Explained by Teachers and Students In HCR focus group discussions, teachers and students cite various additional factors contributing to poor learning outcomes. These include: • Inadequate financing of education. Currently, there are an estimated 80,000 teachers, of which only 35,000 are on the Government payroll. There is also insufficient funding to renovate infrastructure and cover non-salary school operations expenses. Current subsidies, when paid, are equivalent to US$0.50 per pupil for primary school children per term, US$2.5 per pupil per term for junior secondary, and US$3 per pupil per term for senior secondary. The few resources that reach schools are not utilized to focus on addressing foundational learning. Limited funds are available for learning materials, infrastructure, teacher training, and other essential non-salary expenses. • Insufficient teacher professional development and lack of skilled personnel to supervise and coach teachers. Insufficient numbers of adequately trained teachers and a lack of continuous professional development means teachers lack the pedagogic knowledge needed for effective teaching. Supervision of schools and teachers is weak, scarce, and inconsistent – and there is a lack of skilled personnel to supervise, coach, and support school leaders or teachers. Teacher Training Institute reforms have been partial and not coherent with other parts of the education sector. There is no common forum for pre- and in-service teacher educators to share ideas, collaborate or be coherent and consistent with one another. The National Commission for Technical and Vocational Awards (NCTVA) was unfunded for many years, and although the current government has now started providing resources, there is still a long way to go. The benchmark for entering the teaching profession is very low, as candidates must only score above 35 percent to pass. It is unsurprising that teachers lack the awareness of the importance of creating a safe learning environment for children and the pedagogical skills to enable meaningful learning. • Weak school leadership. Regarding school leadership and management, there is no clear job description, no clear understanding of the role of an instructional leader, no required qualification, and nearly no supervision of head teachers. The result is that schools lack sufficiently trained, effective school leaders. • The lack of prioritization of foundational learning in schools. There are too many classes, particularly at the lower end of primary and in many secondary classes, where the number of children is generally high. Teachers are not provided with strategies for teaching children meaningfully in these conditions, so children spend years sitting in class and learning very little. Learning issues start in early grades. • Many young Sierra Leoneans feel disenfranchised and face various forms of abuse in and outside the classroom. Many students are disenfranchised, disrespected, and experience varying degrees of emotional, psychological, and physical (and sexual) abuse as a norm. The Truth and Reconciliation Commission, after the 1990–2002 war, found that the ‘brutality’ of schools was a significant contributing factor to the willingness of youth to take up arms. Even today, corporal punishment is prevalent in many schools despite being made illegal in September 2021. Some students reported that they are faced with antagonistic rather than supportive behaviour in school settings which causes them to disengage from their studies. This is further exacerbated when they observe their peers failing exams, reinforcing a sense of failure. 77 Chapter 3 - Human Capital Outcomes in Sierra Leone • Low levels of community engagement in education. There is no common vision of what a good school looks like, or even good attendance, good child protection practice, good behaviour management, or even what the purposes of school are. Because many parents and community members are illiterate, they are marginalized away from decisions about how schools are run, losing the possibility of engaged parents and community members as a vital resource to the school for governance and local ownership. 3.5 Youth-Oriented Health and Nutrition Services As youth approach adolescence, issues relating to adolescent health, education, employment, and fertility are critical from a human capital perspective. Adolescent Health and Malnutrition Adolescence marks the transition from childhood to adulthood and is a key phase in a person’s physical and cognitive development. Undernutrition in adolescence reduces a person’s ability to learn and work, increases their susceptibility to infection, and retards their recovery from illness. For female adolescents, the risks are even greater, as poor nutritional status increases the risk of obstructed labor, postpartum hemorrhage, and maternal and neonatal morbidity and mortality. This is particularly important as almost half of women in Sierra Leone become pregnant in their adolescent years (DHS, 2019). Malnourishment is a major challenge, with anemia particularly affecting half of the adolescent population. Using the Body Mass Index (BMI), just over a quarter of adolescents in Sierra Leone are classified as malnourished (underweight, overweight, or obese), with rates varying by gender33. In addition, just over half of the female adolescent population and just under half of the male adolescent population are anemic in Sierra Leone. Rural areas have a higher prevalence of underweight and anemic adolescents, while urban areas have a greater proportion of overweight adolescents. The difference by other socio-economic characteristics, such as wealth and education level, do not yield significant results34. 33BMI is an indicator of adult nutritional status that uses a simple index of weight-to-height to classify underweight, overweight and obesity in adults. Specifically, 14.1 percent of female adolescent are classified as underweight, 10.2 percent as overweight, and 1.9 percent as obese. For male adolescents, 22.0 percent are classed as underweight, 3.4 percent overweight and 0.4 percent obese (DHS, 2019). 34In rural areas 16.6 percent of female adolescents are classified as underweight compared to 11.4 percent in urban areas, while 22.9 percent of male adolescents are classed as underweight in rural areas, compared to 20.9 percent in urban areas. Anemia prevalence is also far higher in rural areas, with 56.3 percent of female adolescents in rural areas anemic, compared to 45.5 percent in urban areas, while 54.0 percent of male adolescents in rural areas are anemic compared to 38.4 percent in urban areas (DHS, 2019). Sierra Leone Human Capital Review 78 Adolescent Mortality Sierra Leone has the highest adolescent mortality rate in the world, according to the UN Inter-agency Group for Child Mortality Estimation (World Bank, 2022c). This high level of mortality is driven largely by malaria and injury-related mortalities for male adolescents and maternal and malaria-related mortalities for female adolescents (Figure 3.22). Maternal- and malaria-related mortalities have reduced steadily since 2000 for both male and female adolescents, while all other causes of mortality have remained largely constant, according to modeling conducted by the Institute for Health Metrics and Evaluation (IHME, 2020). While deaths due to maternal complications have been falling in recent years, driven by increased assisted deliveries and pre- and postnatal healthcare, maternal mortalities still accounted for approximately 20 percent of all female adolescent mortality in 2019 (DHS, 2019). Similarly, while malaria-related mortalities have dropped significantly over time, due largely to substantial investments in malaria control35, Sierra Leone still has one of the highest burdens of malaria in the world (IHME, 2020e). High malaria and maternal-related mortalities persist in Sierra Leone largely due to the country’s poor quality of healthcare (see Box 2). Of particular concern is the country’s poor diagnostic accuracy rate for ‘malaria and anemia,’ given that it is a major cause of adolescent mortality. In 2018, only 16 percent of all assessed healthcare professionals correctly identified the co-morbidity (World Bank, 2018). The low availability of quality basic emergency obstetric care and comprehensive emergency obstetric care is also a major concern and primary cause of the country’s high maternal mortality36. Figure 3.22 Causes of Adolescent Mortality by Gender (Deaths per 100,000) Source: IHME (2020c). 35Investments include increasing availability of diagnostic testing, free treatments through the FHCI of 2010, and the mass distribution of insecticide treatment mosquito nets (DHS, 2019; WHO, 2016). 36The adolescent fertility rate (births per 1,000 women ages 15–19) was estimated at 105 in 2020, making it the twentieth highest in the world according to the United Nations Population Division, World Population Prospects (World Bank, 2020c). 79 Chapter 3 - Human Capital Outcomes in Sierra Leone Box 6. Adolescent Mental Health in Sierra Leone Existing research shows high prevalence rates for mental health disorders among youth in Sierra Leone, with implications for their well-being, employability, and human capital (Boston College, 2019). Globally, half of mental health disorders start when people are in their mid-teens, and with 42 percent of Sierra Leone’s population under the age of 15, a mental health system tailored to meet young people’s needs is gravely needed (UNFPA, 2022). Mental health problems are believed to be significant in Sierra Leone due to the country’s civil war, the Ebola epidemic, high levels of poverty, the prevalence of gender-based violence (GBV), and high maternal and child mortality rates. Mental health issues frequently diagnosed include epilepsy/seizures, psychosis, other psychological complaints, moderate-severe depression, alcohol, and other substance use disorders. Furthermore, the stigma associated with mental health treatment, low mental health literacy, a preference for traditional/faith-based healers, and the high cost of medications associated with a treatment are cited as challenges (Hopwood et al., 2021). Suicide is also a real problem faced by youth, with 15 percent of males and 14 percent of females in secondary schools having suicidal thoughts according to a study of Asante et al. (2021) 37. In Sierra Leone, formal mental health care services are limited and not properly integrated into the health system. In 2015, the MoHS established one Mental Health Unit in each district, but there are still not enough mental health workers or clinical psychologists in Sierra Leone. Also, the integration of mental health services into primary, maternal and child health, and HIV care services is extremely limited (Harris et al., 2020). Mental Health Policy (2012) and Strategic Plan In 2012 a national Mental Health Policy was launched, with an updated Mental Health Policy and Strategic Plan currently in the process of finalization. Mental health is included in the Basic Package of Essential Health Services and other national strategic policies and plans, including the Non-communicable Diseases Strategic Plan (2020–2024). Although mental health is included in the Minimum Package of Essential Health Services, health policies, and strategic plans, this has not translated into adequate investment in the country’s mental health system. The launch of the national Strategic Plan and Policy will be vital to guide the improvement of services and mental health literacy among the population. In cooperation with WHO and other partners, the Government of Sierra Leone is developing a new National Mental Health Strategic Plan. Furthermore, a Sierra Leone Presidential Taskforce on Mental Health was recently established with the purpose of advancing the integration of mental health across policies, life stages and targeted Ministries. 37 Data is for an analytical sample of 2,798 students in secondary schools. Sierra Leone Human Capital Review 80 3.6 Employment and Returns to Education in the Working Population The employment phase of the life-cycle is one of the most important from a human capital and economic productivity perspective. The investments (or lack thereof) in health, nutrition, and education in the earlier stages of the life-cycle determine (to a great extent) the ability of individuals to secure income-generating opportunities and improve their welfare. Employment The proportion of the working-age population has increased, and while the working-age population has become more educated over time, more than half of the population has not completed primary education. The share of the working-age population has continued to grow since 1994 (from 52 percent to 57 percent in 2021) (Figure 3.23-a). Between 2003 and 2018, the education levels of the working-age population have also increased: 68 percent were less than primary educated in 2003 compared to 54 percent in 2018, and there have also been increases in other education categories. Despite these gains, a large proportion of the workforce is uneducated, which hinders the ability of human capital to contribute to economic transformation in the country (Figure 3.23-b). Figure 3.23 Evolution and Education Profile of the Working Age Population Source: SLIHS 2003, 2018. 81 Chapter 3 - Human Capital Outcomes in Sierra Leone Most of the workforce is in the agriculture sector, followed by the services sector. Sierra Leone’s economy grew at a constant pace since 2001, with sharp expansion between 2011 and 2014. However, growth between 2003 and 2014 added few jobs to the country’s economy and has not been accompanied by an increase in diversification or an expansion of employment opportunities (World Bank, 2021a). The share of industry in overall GDP peaked between 2010 and 2015, while the share of employment in industry remained relatively constant. Employment is predominantly concentrated in the agriculture and services sectors. As of 2017, 56 percent of the workforce was in agriculture, 38 percent in the services sector, and 8 percent in manufacturing (Figure 3.24). Figure 3.24 Sectoral and Employment Composition in Sierra Leone Source: World Bank Databank, 2022 (left) and World Bank (2021a). The population of Sierra Leone is overwhelmingly young, providing the country with the one-time opportunity to experience rapid economic development as the largest cohort of the working-age population enters the labor market. Forty-two percent of the total population in Sierra Leone is under 15 years (UNFPA, 2022). Youth under 35 years of age account for 75 percent of the population. Sierra Leone had five elderly persons aged 65 or over and 77 children below the age of 15 for every 100 in the working-age population (15–64). Children below 15 comprise the largest sub-group of the population in rural areas, whereas working-age youth (15–35) outnumber other subgroups in urban areas. This age structure allows Sierra Leone an opportunity to reap the ‘demographic dividend’ as the largest cohort of youth enters the labor market. Yet to realize this, the youth need to be well-equipped with proper education and skills, and opportunities need to exist in the labor market to absorb the youth bulge (World Bank 2021a). Overall labor force participation was 69 percent in 2018 and is slightly higher for men than women. However, there are significant differences by urban–rural location. Labor force participation is slightly higher in Sierra Leone than the world average of 66.5 percent and is at par with the SSA average of 68.4 percent. A slightly larger share of men is engaged in the workforce than women. Women’s labor force participation is 67 percent, while men’s labor force participation rate is 71 percent (Figure 3.25). While gender differences in Sierra Leone Human Capital Review 82 labor force participation are marginal, there is a large urban and rural difference: labor force participation rates are 56 percent in urban areas and 81 percent in rural areas, and the gap has widened since 2003. Even though the rural population has a higher labor force participation, rural workers are more likely to be in vulnerable employment than urban workers. Indeed, they are less likely to be regular employees (2 percent compared to 18 percent in urban areas) and more likely to work as helpers in family farms or businesses (35 percent compared to 10 percent in urban areas). Figure 3.25 Labor Force Participation by Gender and Location, 2013 and 2018 Source: SLIHS 2003 and 2018. Relatively low levels of youth labor force participation and high levels of youth engagement in vulnerable occupations are a challenge. Fifty-six percent of youth in Sierra Leone are employed compared to 66 percent of the overall working-age population. Rural youth are more likely to participate in the labor market (74 percent) than urban youth (45 percent), although this gap narrows with age. Most rural youth are employed in agriculture, whereas urban youth are mostly self-employed in non-farm enterprises. Major changes occur between the age of 15 and 34: labor force participation increases slowly with age from 37 percent at the age of 15 to 18, peaking at 90 percent at the age of 35 to 44. The type of employment also changes with age: formal self-employment increases sharply between the ages of 15 and 34, replacing informal employment at household farms or family businesses (Figure 3.26). Figure 3.26 Labor Force Participation at Different Stages of Life 83 Chapter 3 - Human Capital Outcomes in Sierra Leone Source: SLIHS 2003 and 2018. Unemployment and underemployment38 rates are particularly high for urban and more educated youth (Figure 3.27). Within urban areas, youth with relatively high levels of education and from relatively richer households are more likely to be unemployed. Urban youth who have completed secondary education experience the highest unemployment rate (13 percent). Similarly, 8 percent of youth from households in the top 20 percentile of the consumption distribution are unemployed compared to 1.6 percent in the bottom 20 percentile. Regarding underemployment, 16 percent of youth in urban areas are underemployed, and similar to unemployment patterns, youth with higher educational attainment are more likely to be underemployed. Twenty-three percent of youth who have completed secondary education are underemployed compared to 11 percent with no formal schooling. Underemployment is also higher amongst youth in richer households, wage- paying jobs, and in self-employment in non-farm enterprises. To add to the challenge of underemployment, the rates of return to education for all levels of education seem to have decreased between 2003 and 2018 (Figure 3.28). Figure 3.27 Unemployment Rate, 2003 and 2018 Source: SLIHS 2003 and 2018. 38 Underemployment reflects underutilization of the productive capacity of the employed population, including those which arise from a deficient national or local economic system. It relates to an alternative employment situation in which persons are willing and available to engage (ILO, 1999). Sierra Leone Human Capital Review 84 Figure 3.28 Returns to Education, 2003 and 2018 Source: SLIHS 2003 and 2018. Note: Returns to Education, mincerian wage equation: regression coefficients (Log of wage on education, age, age2, gender, rural and urban, standard errors are clustered at district level). Twenty-three percent of youth aged 15 to 24 are not in education, employment, or training (NEET) (Figure 3.29). While this number is relatively lower than other SSA countries, it is high compared to the Organization for Economic Co-operation and Development (OECD) countries (14.7 percent). In 2018, among the youth aged 15 to 35 years old, 24 percent were NEET, and the majority (54 percent) were employed (47 percent were employed, and 7 percent were engaged in both work and schooling) (SLIHS, 2018). Compared to 15 years ago, the NEET rate has stayed relatively stable at 22 percent in 2003, increasing marginally to 24 percent in 2018. However, the employment and education dynamics have changed during this period. Indeed, in 2003, the youth were predominantly either employed or in school, whereas in 2018, a greater proportion of young people were engaged in both employment and education simultaneously. While there is a small difference between the NEET rates for females and males (at 26 and 23 percent, respectively), the urban–rural divide is significant, as 31 percent of youth in urban areas are NEET compared to 17 percent in rural areas (Figure 3.30). These differences are largely driven by the relatively high proportion of youth in employment in rural areas (61 percent), relative to urban areas (35 percent). In terms of regional disparities in NEET, rates vary by district, with Western area Rural and Western area Urban having the highest NEET rates, 37 and 35 percent, respectively, while Port Loko, Koinadugu, and Kambia districts all have NEET rates of 15 percent or less (SLIHS, 2018). Figure 3.29 Share of Youth Not in Education, Employment or Training (NEET) Source: World Bank data portal, Youth aged 15 to 24 years old for global comparison (sub-Saharan Africa) (n.d). Sierra Leone data from SLIHS 2018. 85 Chapter 3 - Human Capital Outcomes in Sierra Leone Figure 3.30 Employment and Education Status of the Youth by Gender and Location Source: SLIHS 2018 Urban youth, females, and less educated youth are more likely to be NEET, although, for youth who have completed senior secondary school and higher education and TVET, the probability of NEET is higher than uneducated youth (Figure 3.31). University-educated youth are also less likely to be employed than uneducated youth. Rural youth are less likely to be NEET (since they are more likely to be engaged in economic activity), while the probability of being NEET for females is 28 percentage points higher than for males. Primary or less educated youth are more likely to be NEET than junior secondary-level educated youth. It is interesting to note that youth that have completed senior secondary or higher TVET are more likely to be NEET than primary or less educated youth. This could reflect the nature of the labor market. While unskilled and less educated youth are engaged in low-productivity (and low-skilled) economic activity, there may be fewer opportunities for more educated youth looking for relatively higher-paying and higher-skilled jobs. This may also be true for youth that have completed university education, as reflected in the figure below. Youth that have completed university or higher education are significantly less likely to be engaged in economic activity than primary or less educated youth. Poverty status does not explain the variation in NEET, which is understandable, as poor youth are more likely to work compared to their non-poor counterparts and are less likely to be in school. Sierra Leone Human Capital Review 86 Figure 3.31 Determinants of NEET, Working and Schooling for All Youth Source: Author’s calculations using SLIHS 2018. Note: Regressions are estimated using logistic regressions, and standard errors are clustered at the sampling cluster level. The variables included in the regression but not shown are the household head’s education, welfare decile indicators of the household, and number of household members. The poor are defined as the poorest 40 percent in income proxy (per capita expenditure). 87 Chapter 3 - Human Capital Outcomes in Sierra Leone The correlates of the probability of being NEET for urban and rural youth differ, with rural females being particularly disadvantaged. The probability of being NEET in rural areas for females is much higher relative to males than in urban areas after controlling for other factors. This is because rural female youth are less likely to work than males, while urban female youth are equally likely to work as are males. For education levels, youth that have completed senior secondary (relative to those that have completed primary or lower) are more likely to be NEET in urban areas, although this is not the case in rural areas. Youth that have completed TVET are less likely to be engaged in economic activity in urban areas (relative to those that have completed primary or lower), and youth that have completed higher education are less likely to be engaged in the labor market than primary or lower educated youth, and this is more pronounced in rural areas than urban areas (potentially indicating a lack of opportunities for highly educated individuals in rural areas). Youth Employability Challenges A relatively small share of NEET are actively looking for jobs, and the main obstacles to finding work include financial constraints, lack of skills/experience, and taking care of the home/family. When asked about their intention to find a job, only 11 percent of the NEET youth had tried to find a job in the previous four weeks, and this is particularly low for rural and female youth (6 and 7 percent, respectively). NEET youth with a higher level of education are more actively job hunting, with 23 percent of the NEET youth with higher TVET and 12 percent with college education having tried to find a job in the previous four weeks. The main reasons for not looking for work include a lack of financial resources and having to contribute to household work, followed by the lack of required skills and experiences. However, these reasons vary by location and gender (Figure 3.32 and Figure 3.33). A lack of financial or other resources is the most important reason cited by urban youth (17 percent) and males (20 percent), while taking care of household work is the most important reason for rural youth (23 percent) and female youth (19 percent). Lack of required skills or experience is important for urban youth (14 percent) but less of a factor for rural youth (6 percent). Figure 3.32 Reasons for Not Looking for a Job by Location Source: SLIHS 2018. Sierra Leone Human Capital Review 88 Figure 3.33 Reasons for Not Looking for a Job by Gender Source: SLIHS 2018. Low educational attainment and the low quality of education are inhibiting many individuals from securing employment. Educational attainment is an important indicator of employability prospects for youths. Well-educated individuals are more likely to get decent jobs and earn higher disposable incomes than their uneducated counterparts. Similarly, high-quality education provides students with the required skills and knowledge to enter into and succeed in the job market. Beyond basic literacy and numeracy (which, as discussed earlier, remains a challenge), the modern job market values skills related to critical thinking, problem-solving, and effective communication, and the education system in Sierra Leone is currently not producing graduates equipped with those skills. There is a lack of opportunities for the youth due to an undiversified economy. Since the end of the civil war in 2002, the economy of Sierra Leone has made steady progress in reviving its ailing economy. However, despite maintaining positive growth rates of 7.6 percent per annum between 2003 and 2014, it failed to achieve structural transformation and economic diversification. The Government has found it increasingly difficult to create productive employment for its teeming youth population. Additionally, the economy has faced several shocks, such as the Ebola crisis, the decline in iron ore prices, the COVID-19 pandemic, and, more recently, the Russia–Ukraine war. All of these issues have negatively impacted economic growth and further weakened macroeconomic fundamentals. Low productivity of agriculture and changing attitudes towards working in the sector. The Sierra Leone economy is monolithic and relies on the low-productivity agriculture and services sector for employment and revenue generation. While agriculture employs many, due to the lack of mechanization and weak value chain in the sector, it fails to provide people with sufficient income to escape the poverty trap. In 2003, around 67.3 percent of laborers were employed in agriculture. However, 10 years later, the share of total employment declined to 61.1 percent. This trend can be explained by the low-value addition of the sector and the changing attitudes and perceptions of agriculture as a source of livelihood. From consultations with stakeholders, agriculture is no longer considered attractive by many young people due to the existence of other opportunities and the dwindling state of the sector. Numerous barriers to doing business in Sierra Leone limit the potential for self-employment. The ease of doing business is a ranking based on indicators that determine whether a country is conducive to starting and operating a local business. Over the past decade, Sierra Leone’s Ease of Doing Business ranking averaged 150, making it one of the worst performers globally. In 2020, it was ranked 163 and scored particularly poorly on the following topics: dealing with construction permits; getting electricity; registering property; getting credit; protecting minority investors; trading across borders; enforcing contracts; and resolving 89 Chapter 3 - Human Capital Outcomes in Sierra Leone insolvency. While youth entrepreneurship is a viable pathway to reducing youth unemployment by creating job opportunities across sectors and empowering individuals to run their businesses, the absence of an enabling environment, conducive policies, and market forces that drive demand make starting and running a business a difficult endeavor in Sierra Leone. There is a mismatch between the supply and demand for skills. This refers to a discrepancy between the skills that are available in (or supplied to) the labor market and the skills that are in demand in the labor market. According to a 2017 report by the International Labor Organization (ILO), the term ‘skills mismatch’ captures a variety of scenarios, including (a) vertical mismatch: where individuals are over- or under-qualified or skilled for a job; (b) horizontal mismatch/skill gaps: where firms are unable to attract the right skills for positions; and (c) skill obsolescence: where individuals possess skills that have become obsolete or are outdated due to technological advancement and the evolution of the labor market. In Sierra Leone, according to a skill needs assessment study focusing on strategic sectors with high potential for economic growth and job creation, employers faced challenges in filling job vacancies due to low technical skills and lack of practical experience of candidates (GIZ, 2018). The issue of skills mismatch was identified as one of the key issues limiting youth employment outcomes during stakeholder consultations. Despite attending higher education institutions, the youth workforce in Sierra Leone still lacks both foundational and technical skills that will enable them to compete for jobs both in the domestic and international labor market. Related to the skill mismatch issue is the low enrollment levels in Science, Technology, Engineering, Agriculture, and Mathematics (STEAM) programs, particularly for women. Only three out of every 10 tertiary education students are enrolled in STEAM degree programs. Moreover, women are underrepresented in STEAM: only one in five women are in STEAM compared to one in three men. While the number of male students in STEAM grew by 10 percentage points between 2017 and 2019, the number of female students only grew by 5 percentage points. The Government is committed to improving women’s participation in STEAM, and all women applying to STEAM courses are provided with scholarships to incentivize their enrollment (GoSL, 2020). Lack of inclusive and sustainable policies. To strengthen the policies and frameworks for employment in the country, the Government of Sierra Leone has designed several policies and initiatives since the end of the civil war. Some of them include the Youth Employment Support Project (YESP), which is funded by the World Bank and implemented by the National Commission for Social Action (NaCSA) and the National Youth Commission (NAYCOM) in collaboration with other relevant Ministries, Departments and Agencies (MDAs) There is also the Private Sector Development Strategy, developed by the Ministry of Trade and Industry in 2009, and, more recently, the National Youth Policy, revised in 2020 by the Ministry of Youth Affairs. Despite the laudable objectives of these initiatives, youth employment remains a challenge, and policy and program formulation need to be more inclusive. Based on stakeholder consultations, this is due to several factors, such as (a) a lack of inclusiveness and democratization of the policy-making process; (b) inadequate funding and capital resources to sustain these reforms; and (c) policy inconsistency and deviation often driven by political motivations. High rates of rural–urban migration. Recently, there has been a mass exodus of youths from rural to urban areas. A 2017 study by Statistics Sierra Leone indicates that 25 percent of the population does not live in the district where they were born. Furthermore, the study found that the Western Region is most popular for both lifetime and recent migration, while the Northern Region has the highest number of emigrants. In terms of demographic profile, most migrants are young and male39. This trend in migration patterns can be explained by the perception that urban regions possess better opportunities and physical and social infrastructure to improve their quality of life. The youth who choose to migrate exhibit a relatively higher level of education, most of them falling within the top 60 percentile in terms of their consumption patterns (SLHIS, 2018). For instance, male urban migrants are more likely to have formal schooling and to hold at least a secondary level education. However, in the absence of the requisite skills and educational qualifications to find jobs, alongside the shortage of opportunities, several young people are idle and susceptible to social vices such as cultism, crime, and drug abuse. Thus, the issue primarily arises for the uneducated and unskilled workforce that migrates to urban areas. 39 However, among the youth that migrates, 56 percent are female (World Bank, 2021a). Sierra Leone Human Capital Review 90 Photo © Dominic Chavez/World Bank 3.7 Adolescent Fertility For many in Sierra Leone, adolescence marks the beginning of sexual activity, with women typically beginning sexual intercourse earlier than men. In 2019, the median age at first sex was 15 years old for women aged 20–24 and 17 years old for men aged 20–24, with 85 percent of women (aged 20–24) reporting having sexual intercourse by age 18, an increase from 69 percent in 2013. This compares to 68 percent of men (aged 20–24) having sexual intercourse by age 18, a decrease from 71 percent in 2013 (DHS, 2019; DHS, 2013). Adolescent Fertility in Sierra Leone Sierra Leone has one of the highest adolescent fertility rates in the world, driven by the country’s high rural adolescent fertility rate (DHS, 2019; MoHS, 2018). Figure 3.34 presents the adolescent fertility rate for the three years preceding each year listed. As the graph shows, Sierra Leone’s adolescent fertility rate has declined in both rural and urban areas over the period shown, but remains remarkably high, especially in rural areas, where adolescent fertility rates are more than double urban adolescent fertility rates (DHS, 2019). Unsurprisingly, adolescent fertility levels fall dramatically as educational attainment and wealth increase (DHS, 2019). 91 Chapter 3 - Human Capital Outcomes in Sierra Leone Figure 3.34 Adolescent Fertility Rate by Location (births per 1,000 female adolescents) Source: DHS (2008, 2013, 2019), UNICEF (2017). The Consequences of Adolescent Fertility Sierra Leone’s high adolescent fertility rate has significant implications for the human capital of both mother and child. Children born to adolescents are at far greater risk of mortality, with infant and child mortality rates on average 20 percent higher for adolescents than for non-adolescent mothers (Table 3.7). Moreover, mortality rates are higher among children whose mothers previously gave birth as adolescents. If adolescent births are omitted from the analysis (i.e., excluding all children born to adolescent mothers from the analysis), the predicted probability of a mother, as an adult, losing a child under-5 is 33 percent for those who had their first birth as an adolescent and 22 percent for those who did not give birth as adolescents. These data show the enduring effects of adolescent pregnancy, with this higher mortality rate in part explained by a greater prevalence of high-risk fertility behaviors among females who were pregnant as adolescents40 (DHS, 2019). Table 3.7 Infant and Child Mortality Rates by Mother’s Age (deaths per 1,000 live births) NNMR PNNMR IMR CMR U5MR Age group (0–1 month) (2–12 months) (0–12 months) (1–4 years) (<5 years) Adolescent 34 55 89 58 142 Non-adolescent 30 43 73 49 118 Source: DHS (2019). 40 The probability of a mother’s birth spacing being less than two years at any point in her life is 36 percent if she gives birth as an adolescent, compared to 15 percent if she does not. The probability of a mother having multiple short birth intervals is 32 percent if they give birth as an adolescent, compared to 21 percent if they do not. The expected number of children for women who have given birth as adolescents is 5.9 compared to 4.5 for those who do not (DHS, 2019). Sierra Leone Human Capital Review 92 Women who give birth as adolescents are more likely to forgo education, drop out of the workforce, experience pregnancy-related risks, and be married as children (DHS, 2019). In Sierra Leone specifically, expected years of schooling are 56 percent higher for women who do not give birth as adolescents compared to those that do, at 5 years and 3.2 years, respectively; adolescent pregnancy is also strongly associated with child marriage, with 77 percent of childbearing adolescents41 married, compared to just 11 percent of non-pregnant adolescent females, while maternal mortality is accountable for approximately 20 percent of female adolescent deaths42 (DHS, 2019). All of this significantly and adversely affects human capital. Significantly, child marriage (under 18) precedes early childbearing (giving birth as an adolescent) in 76 percent of cases in Sierra Leone43 (DHS, 2019). While this is an imperfect method for determining causality, with child marriage preceding childbearing in over three-quarters of cases, early marriage appears to be a key determinant of early childbearing in Sierra Leone (DHS, 2019). While Sierra Leone has made significant advancements in reducing child marriage, over a quarter of girls still marry before the age of 18, and 14 percent before their sixteenth birthday (DHS, 2019). This presents significant risks to these children, including reduced agency and decision-making; increased exposure to violence, abuse, and discrimination; and reduced education and economic, political, and social participation (UNOHCR, 2023). Child marriage is noticeably affected by girls’ educational attainment, with only 3 percent of females aged 15–19 married and in school, compared to 33 percent of 15–19-year-old non-married females in Sierra Leone (World Bank, 2020c). This finding is similar throughout West and Central Africa, with lower secondary completion rates among West and Central African countries far lower among those with a higher prevalence of child marriage. The Causes of Adolescent Fertility and Child Marriage in Sierra Leone There are significant differences in adolescent and child fertility rates by socio-economic groups in Sierra Leone, as shown in Figure 3.35. This graph uses data from DHS (2019) to show the percentage of women aged 20–24 that gave birth as adolescents (age 19 and under) and that gave birth as children (under 18 and under 16 years old). The most significant findings are that almost two-thirds of rural females give birth by age 18 and that the adolescent birth rate for those with no or primary education is 66 percent, compared to 43 percent for those with secondary education and 18 percent for those with higher education. The adolescent and childbirth rates for the poorest three quintiles are remarkably similar and average twice that of the richest quintile, as shown in Figure 3.35. Early childbearing also differs by district, with Moyamba and Pujehun having the highest under-20, under-18, and under-16 birth rates in Sierra Leone (DHS, 2019). 41 Adolescents that are pregnant or have given birth. 42 Maternal mortality rates by five-year age groups are calculated by dividing the number of maternal deaths to female siblings of respondents in each age group by the total person-years of exposure of the sisters to the risk of dying in that age group during the seven years preceding the survey (DHS, 2019). 43 Marriage precedes child bearing if the marriage occurs before the child is born, if the child is born within six months of marriage (i.e., marriage occurs when at least three months pregnant). 93 Chapter 3 - Human Capital Outcomes in Sierra Leone Figure 3.35 Percentage of Women Aged 20–24 Who Gave Birth as Adolescents (under 20) and as Children (under 18 and under 16) Source: Author’s interpretation of DHS (2019). Note: *Higher refers to above secondary education. Data is not available for sufficient data points (>25) for above secondary education for ‘live birth under 18’ and ‘live birth under 16’, so no analysis is presented. Unsurprisingly, adolescent education was found to be by far the most significant factor affecting child marriage and adolescent fertility. Inferential analysis was conducted to better understand the influence of socio-economic factors on adolescent fertility and child marriage, controlling for a host of potentially influential variables44. The predicted probability of giving birth as an adolescent is 58 percent for those with no or primary education, 47 percent for those with secondary education, and 30 percent for those with greater than secondary education (DHS, 2019). Education protects girls from early marriage and, by extension, early childbearing. Yet, for many, misconceptions over the low value of female education and the lack of employment opportunities for educated females causes them to be removed from school and married, with marriage and schooling viewed as incompatible. This not only affects girls removed from school today, but has significant implications for future generations, as access to quality education is critical to breaking the cycle of poverty and gender inequality and preventing the intergenerational transmission of child marriage (World Bank 2020; UNICEF, 2022). The predicted probabilities of child marriage and early childbearing are practically and/or statistically insignificant by region, ethnicity, religious affiliation, and household size, but are lower for the wealthiest quintile. The predicted probability of giving birth as an adolescent is remarkably similar for the first four wealth quintiles (poorest to richer), averaging 54 percent, with the predicted probability for the richest quintile only marginally lower at 49 percent (DHS, 2019). The same is true for the probability of girls marrying before age 18, with the predicted probability of being married before age 18 remarkably similar for the first four wealth quintiles (poorest to richer), which average 37 percent, and which are lower for the richest quintile at 28 percent (DHS, 2019)45. The importance of education in delaying child marriage and adolescent fertility is also reported in a World Bank report (2020), which finds that ‘each additional year of secondary education may reduce the risk of child marriage by 10 percentage points’ in Sierra Leone. Given the close correlation between educational attainment, child marriage, and early childbearing among girls in Sierra Leone, one of the most effective interventions to reduce the prevalence of child marriage and early childbearing is to incentivize girls to remain in or go back to school. 44 Regression controlled for wealth, education, region, ethnicity, and religious affiliation. 45 Given this analysis, it is not surprising that the predicted probability of sexually active female adolescents using modern contraception also increases significantly with education. Controlling for a host of socio-economic variables, the predicted probability of using modern contraceptives among sexually active female adolescents is 48 percent for those with secondary or higher education and 30 percent for those with primary or no education (DHS, 2019). Sierra Leone Human Capital Review 94 Photo: © Dominic Chavez / World Bank National Strategy for the Reduction of Adolescent Pregnancy and Child Marriage (2018–2022) Sierra Leone is facing a double burden of child marriage and adolescent pregnancies. These two entangled problems are depriving girls from reaching their full potential. Given the challenge of these problems to the national development, the Government of Sierra Leone introduced the National Strategy for the Reduction of Adolescent Pregnancy and Child Marriage (2018–2022) in 2018. The Strategy was developed to guide the implementation and prioritization of interventions to reduce adolescent pregnancy and child marriage in Sierra Leone. It includes key targets around adolescent maternal mortality and fertility, child marriage, sexual activity, use of family planning services, and the provision of adolescent-friendly health services. In addition, the country has statutory instruments that seek to address the challenge of teenage pregnancy and child marriage, including the Sexual Offences Act (2012), the Child Rights Act (2007) and the Registration of Customary Marriage and Divorce Act (2009). All these instruments prohibit the practice of marriage or sexual encounter with persons below the age of eighteen years. However, the Registration of Customary Marriage and Divorce Act (2009) makes provision for the marriage of boys and girls under 18 years old with their parents’ consent, effectively permitting child marriage. 95 Chapter 3 - Human Capital Outcomes in Sierra Leone Adolescent Contraception Use Analysis of the DHS (2019) shows that 39 percent of pregnant or childbearing female adolescents did not want their most recent child at the time of conception. Improving knowledge of and access to family planning and sexual health services can help prevent unintended and high-risk pregnancies. It can also help women and couples achieve their desired family size, increase birth spacing, reduce maternal mortalities, and improve female educational outcomes and gender inequality. Despite the significant benefits of family planning services, contraception use remains low among adolescents in Sierra Leone, with many harboring misconceptions about contraceptive issues (UNFPA, 2020; DHS, 2019). Only 45 percent of sexually active, unmarried female adolescents used modern contraceptives in 2019, compared to 53 percent of unmarried women aged 15–49 (DHS, 2008 and 2019). Despite representing a significant improvement from 2008, when just 19 percent of sexually active, unmarried female adolescents used modern contraceptives, less than half of this group were using contraceptives in 2019 and were thus exposing themselves to sexually transmitted infections and unwanted pregnancy. Alarmingly, only 20 percent of adolescents reported an unmet need for family planning despite 55 percent not using modern contraceptive methods. This demonstrates a lack of demand for family planning and a significant demand- side barrier to improving access and reducing adolescent fertility rates. While knowledge of modern contraceptive methods is high, use remains low, with many adolescents demonstrating a lack of education regarding sexual health. Among adolescents, 95 percent of female 15–19-year-olds and 95 percent of male 15–19-year-olds were aware of at least one modern contraceptive method. While knowledge of modern contraceptive methods is high, use remains low, with many adolescents demonstrating a lack of education regarding sexual health. Specifically, among sexually active female adolescents, 17 percent do not use modern contraceptives because they are either ‘not married,’ ‘have infrequent sex,’ or both, leaving them susceptible to unwanted pregnancies or sexually transmitted infections. In addition, 21 percent of sexually active female adolescents do not use modern contraceptives because either they or their partner are ‘opposed’ to the idea, while 7 percent do not use modern contraceptives because of ‘health concerns/side effects,’ demonstrating a clear lack of understanding around sexual health (DHS, 2019). A large proportion of the female adolescent population who are sexually active and neither pregnant nor desire to be pregnant are not using contraception in Sierra Leone. Misunderstandings around contraceptives and sexual health are limiting contraceptive use, with opposition to contraceptives being a significant reason for non-use among both boys and girls (Labat et al., 2018; DHS, 2019). Lack of access may also present issues. A recent study by Labat et al. (2018) found that lack of access to contraceptives was an important factor behind low use among male youth in Sierra Leone (under 24 years old). A focus group discussion with youth in Freetown, Sierra Leone, in January 2023, reported that a lack of youth-friendly health services prevents easy access to contraceptives, with judgments made by health staff when trying to access family planning services deterring many from seeking such services. Furthermore, with the COVID-19 pandemic causing prolonged school closures, the risks of early marriage and/or childbearing among adolescent girls could have heightened, as was seen in the Ebola epidemic (World Bank, 2020c). This is likely to lead to rising adolescent pregnancies and school dropouts among vulnerable groups, with Save the Children predicting a 25 percent increase in the rate of adolescent pregnancy during the 2020 school closures (UNICEF and Irish Aid, 2021). Sierra Leone Human Capital Review 96 3.8 Life Expectancy, Mortality, and Retirement Mortality Trends and Life Expectancy in Sierra Leone Sierra Leone’s adult survival rate is very low compared to regional and income-level benchmarks. The adult survival rate, the last component of the HCI, refers to the probability of surviving from ages 15–60. It is a proxy for the range of health risks a child will face as an adult under current conditions. The probability of surviving in Sierra Leone from age 15 to 60 is just 0.63 (World Bank, 2020e). In comparison to all other low-income countries (LICs), Sierra Leone has the second lowest adult survival rate , and in comparison to the rest of SSA, Sierra Leone has the fourth lowest survival rate46, as illustrated in Figure 3.36. However, it is important to note that despite its relatively low ranking, Sierra Leone has made significant progress in improving its adult survival rate over the years, even in the face of challenging economic and health shocks. Figure 3.36 Probability of Survival from Age 15–60 Source: World Bank (2020c)47. In recent years, adult mortality rates for both genders and all age groups have declined in Sierra Leone (DHS, 2008, 2019). However, the Ebola virus epidemic caused a spike in adult mortality rates in 2014, with adult mortality rates increasing by approximately 25 percent (IHME, 2020c). There were 2,46148 confirmed deaths reported in Sierra Leone due to the virus, which had a high mortality rate among infected individuals. In addition to the direct impacts, the outbreak indirectly affected the health system, with disruptions to routine health services and decreased immunization coverage, as people lost confidence in health workers during the outbreak. The Ebola virus outbreak also hindered people from seeking healthcare for other illnesses, with a 70 percent decline in inpatient admissions during the outbreak (Helleringer and Noymer, 2015). 46 Data is available for 24 LICs. 47 Adult Survival Rate is calculated by subtracting the mortality rate for 15–60 year-olds from 1. Mortality rates for 15–60 year-olds are retrieved from the United Nations Population Division World Population Prospects, 2019 data release, supplemented with data provided by the World Bank. Most recent estimates as of 2019 are used. 48 As of December 2014. The number of deaths is suspected to be higher as probable and suspected cases are not included in this figure. 97 Chapter 3 - Human Capital Outcomes in Sierra Leone Sierra Leone has witnessed a substantial improvement in its overall life expectancy over the last twenty years (Figure 3.37). The end of the civil war, during which Sierra Leone’s life expectancy was considerably lower than its SSA and LIC counterparts, marked the beginning of the country’s improvement in life expectancy. In recent years, Sierra Leone has caught up and surpassed its neighbors with a higher life expectancy rate than the Western and Central Africa average. Figure 3.37 and Figure 3.38 demonstrate the profound impact of the 1991–2002 civil war on the country’s demographics, with this decline affecting men more than women. Figure 3.37 Life Expectancy, Regional Comparisons Source: World Bank (2020b). Figure 3.38 Life Expectancy by Gender Source: World Bank (2020b). Sierra Leone’s increase in life expectancy has significant implications for human capital, with reductions in mortality increasing incentives to invest in education and health due to the potential for improved returns. Investments in the country’s population become more valuable if the potential returns extend over a longer period. With Sierra Leone’s life expectancy increasing dramatically and with the country experiencing a significant youth bulge, investments in human capital formation are not only more attractive but imperative if the country is to benefit from its current demographic dividend (Jayachandran and Lleras-Muney, 2009; Oster, Shoulson, & Dorsey, 2013). Sierra Leone Human Capital Review 98 Causes of Mortality In Sierra Leone, most adult mortalities up to age 50 are due to preventable and curable diseases, with communicable diseases such as malaria, HIV/AIDS, and respiratory infections as the main cause of mortality for working-age adults (Figures 3.39 and 3.40). Despite implementing the National Malaria Control Program49, key challenges persist, including a lack of human resources to coordinate and implement the program in rural districts and limited supply chains at all levels. These constraints hinder the delivery of effective malaria prevention and control measures to those in need. Moreover, HIV/AIDS rates remain significant causes of mortality, with the escalating prevalence of infection attributed partly to low utilization of contraception due to poor sexual health knowledge, with women in rural areas demonstrating a noticeably lower understanding of sexual health50. Despite the availability of free treatment, Sierra Leone still has one of the highest tuberculosis burdens globally, with the shortage of human resources and long distances to health facilities acting as the primary challenges to program effectiveness (WHO, 2017). Sierra Leone opened its first drug-resistant tuberculosis treatment center in 2017, but more efforts are needed to combat this preventable disease effectively. Addressing these challenges through implementing effective preventive and control measures can help reduce the prevalence of preventable and curable diseases in Sierra Leone, ultimately saving lives and promoting sustainable development. Diverse mortality patterns can be observed when examining causes of death by gender. According to DHS (2019), adult mortality is higher among men for all age groups except for ages 25–29 years, when maternal mortality rates are at their highest. The adult mortality rate (age 15–49) in Sierra Leone is 4.69 deaths per 1,000 population for women and 5.59 deaths per 1,000 for men (DHS, 2019). Mortalities related to malaria, HIV/AIDS, and cardiovascular diseases are widespread among both genders, while maternal mortality is the primary cause of death among adult women of childbearing age. Among women aged 45–49, cardiovascular diseases are the leading cause of death, followed by malaria and cancer (IHME, 2020e). Moreover, obesity has increasingly impacted women’s health, with 28 percent of adult women overweight or obese in 2019, compared to 18 percent in 2013 (DHS, 2019, 2013). HIV/AIDS and malaria are significant causes of death among all working-age men, with injuries being a significant cause of death, particularly among young adults (under 30) due to the physically demanding nature of their work, particularly in the agricultural sector, where injuries such as lacerations, crushing, and falls are frequent (Stewart et al., 2013). Non-communicable diseases (NCDs) are widespread in Sierra Leone but increase in prevalence with age and are the major causes of mortality for both men and women over 50. Dietary hazards and high systolic blood pressure were the most important risk factors for NCDs in both 1990 and 2017, indicating the persistence of these issues over time (Zembe et al., 2022). While the country’s high prevalence of hypertension and alcohol and substance abuse, and the country’s high BMI, further increase the risk of NCD-related mortalities. Most notably, from age 50, cardiovascular disease becomes the most common cause of death for both males and females, followed by respiratory infections, cancer, malaria, and diarrheal diseases (IHME, 2020e). While NCDs become the dominant cause of death as both males and females age (IHME, 2020e), preventable and curable diseases such as malaria, diarrheal diseases, and respiratory infections remain major causes of mortality, showing the importance of tackling both communicable and non-communicable diseases among adult populations. 49 The Ministry of Health administers the program that disseminates insecticide-treated nets and facilitates access to malaria preventive therapy. 50 Sexual diseases transmission awareness is a challenge. Only 62 percent of women aged 15–49 understood that a healthy-looking person can be HIV-positive, with geospatial disparities evident. Women living in rural areas account for a smaller percentage of this group (51 percent), while women in urban areas have higher awareness levels (73 percent). This knowledge also increases with wealth and education, as expected (UNICEF, 2017). 99 Chapter 3 - Human Capital Outcomes in Sierra Leone Figure 3.39 Causes of Male Adult Mortality (deaths per 100,000 persons) Source: IHME (2020c). Figure 3.40 Causes of Female Adult Mortality (deaths per 100,000 persons) Source: IHME (2020c). Sierra Leone Human Capital Review 100 The provision of adequate care for mental illness in Sierra Leone remains severely inadequate, with less than 2 percent of adults with such conditions receiving appropriate treatment in 2019 (Hopwood et al., 2021). Several factors contribute to the neglect of mental illness in Sierra Leone. The limited availability of mental health facilities outside the capital, Freetown, is a major constraint as the limited psychological and psychiatric care services are mainly centralized in the country’s main urban center. Moreover, despite concerted efforts to tackle the issue, a shortage of adequately trained professionals in the mental health field persists, significantly impeding care delivery. In addition, the social stigma associated with seeking mental health treatment represents a significant barrier, with families often seeking alternative avenues for mental health care, such as traditional healers and faith-based organizations. These challenges are discussed in greater detail in the adolescent health section. NHSP (2021), NHSSP (2021), UHC roadmap (2021), SLeSHI (forthcoming) The Government of Sierra Leone, through the MoHS, has developed three standard policy documents – the National Health and Sanitation Policy (2021), the National Health Sector Strategic Plan (2021), and the Universal Health Coverage Road Map (2021) – that focus on building resilient health systems that are capable of providing access to quality and affordable essential health and sanitation services for the general population. The National Health Sector Strategic Plan (2021) provides a comprehensive implementation framework to help move the country towards Universal Health Coverage, with the National Health Financing Strategy aiming to support adequate and sustainable healthcare financing efforts in Sierra Leone to improve population health outcomes. Given the high out-of-pocket expenditures in Sierra Leone, the Government is also in the advanced stages of launching a social health insurance scheme (Sierra Leone Social Health Insurance scheme [SLeSHI]) to provide affordable health care by reducing out-of-pocket expenditure and improving access and equity to health care services. 101 Chapter 3 - Human Capital Outcomes in Sierra Leone Chapter 4 Drivers of (or Challenges to) Human Capital Formation This chapter identifies the main factors inhibiting sustainable and equitable human capital formation, focusing on broad cross-cutting issues such as poverty, governance, food security, social norms, financing, digital economy and innovation, climate change, gender, disability and inclusion, and pandemic and resilience to shocks. Photo: © Moses Alex Kargbo / World Bank 4.1 Poverty More than half of the country’s population lives in poverty. Sierra Leone has experienced economic growth in the decades following the civil war. Although this has generally translated into poverty reduction in the country, poverty remains high compared to other SSA countries. Between 2003 and 2011, the poverty rate reduced by approximately 14 percentage points (World Bank, 2013). In 2018, the poverty rate decreased moderately by 6 percentage points to 56.8 percent51 . Poverty in rural and urban areas shows great disparity, with the incidence of poverty in rural areas (74 percent) being double that in urban areas (35 percent). Looking beyond income as a measure of poverty, the national multidimensional poverty rate in 2017 was 64.8 percent. This means that approximately two-thirds of the population are classified as deprived in education, health, housing, and access to basic services such as water and sanitation, all of which are critical to human capital accumulation. Similarly, the incidence of multidimensional poverty in rural areas (86.3 percent) is more than double that in urban areas (37.6 percent). Furthermore, Sierra Leone’s vulnerability to climate-related disasters, health crises, and economic shocks continues to threaten poor households and households slightly above the poverty line. Low-income households usually adopt negative coping strategies, which further drive them into poverty during these shocks. The high level of poverty in Sierra Leone extensively inhibits the demand for basic services and the capacity of households to invest in human capital development. To a large extent, the income level determines the amount of human capital investments a household makes. For the approximately 13 percent of children ages 6–17 who have never attended school, about 23 percent cited costs associated with education as a reason. Even for children who attended school, the completion rate is lower for rural and poorer households. Households in the poorest quintile spend approximately 9 percent of total expenditures on education and health, while the richest quintile spends about 14 percent (World Bank, 2021). High poverty prevalence also has implications for investments in health and nutrition. Similarly, households in the richest quintiles spend a higher proportion of total household expenditure on healthcare than the poorest quintiles (World Bank, 2022a). Additionally, food poverty, recorded as 54.5 percent in 2018, is the major contributor to the overall poverty rate of 56.8 percent. Food items are a large proportion of the consumption basket of poor households, so the high food inflation, which was exacerbated during COVID-19, has reversed the gains in poverty reduction. These constraints limit the capacity of households to invest in healthcare and diversify their diet, which has negative consequences on mortality, food security, and stunting rates. Over the two decades following the civil war, the Government has launched several programs targeting the poor and extreme poor to boost human capital development amongst the most vulnerable in the country. The Sierra Leone Social Protection Strategy 2022–2026 outlines priority areas for investment to meet the objectives of the Social Protection Policy 2019. Sierra Leone’s flagship social assistance program, Ep Fet Po, was launched in 2014 to provide unconditional cash transfers to extreme poor households. Since its inception, the Program has provided cash transfers to 606,700 beneficiaries, which represent over half of the extreme poor population. Results from a rapid assessment of the Program conducted in 2018 reported that beneficiaries used the cash transfers to improve investments in health and education and enhance the welfare of their families. Forty-four percent of beneficiaries used the cash transfers to cover school expenses, 40 percent bought more food of higher nutritional value, and 12 percent invested in productive activities such as the establishment of microenterprises. The assessment also reported that compared to non-beneficiaries, beneficiaries of the program were more likely to enroll school-aged children in schools and seek health services when children are sick. As mentioned earlier, the Government also implements programs offering free education and healthcare services through the FQSE Program and the FHCI. 51 According to the main findings of the SLIHS 2018, the 2018 poverty rate of 56.8 percent is not directly comparable to the 2011 poverty rate of 52.9 percent, due to differences in methodology and increase in the national poverty line for 2018. However, adjusting for these changes, poverty decreased by 5.6 percentage points. 103 Chapter 4 - Drivers of (or Challenges to) Human Capital Formation There is still a need for greater investments to ensure the poorest households in the country can benefit from education and health care services. Although the Government has made progress in improving access to healthcare services and education for the poor and extreme poor through these programs, challenges such as inefficiencies in reaching the targeted beneficiaries and the inadequacy of cash transfer benefits and coverage persist. Even though the FQSE Program covers tuition fees and textbooks for primary and secondary school children, poor households are still burdened with most of the other educational expenses, such as uniforms, extra lessons, supplementary materials, and transportation. Additionally, analysis of the roll-out of the FQSE Program revealed that more approved schools in less poor communities benefited from the program. Similarly, although access to healthcare facilities has increased, only 40 percent of households in rural areas have a clinic within a 30-minutes distance. Adding to this, households still report out-of-pocket costs for the treatment of sick children under-5, despite the FHCI. To increase the use of healthcare services for the poor and extreme poor population, further efforts must be made to ensure that the benefits reach the intended beneficiaries. To maximize the effects of these various initiatives, social protection programs should be scaled up to increase coverage and benefit sizes, given the country’s high incidence and intensity of poverty. 4.2 Governance Weak governance, management, and accountability systems are limiting the effectiveness of service delivery. As discussed in Chapter 2, the Local Government Act has devolved the responsibility for health and basic education service delivery to local councils. However, while legal responsibility has been largely devolved, in practice, numerous challenges persist. In the health sector, district health facilities face shortages of health and administrative personnel, facilities are underequipped, and there are regular drug shortages. District Health Management Teams (DHMTs) lack effective financial management, internal audit, procurement, contract management, monitoring and evaluation, and health management information systems. In the education sector, the mandates of the District Education Office and the local council have not been clearly defined. Grants from the central government to the local governments are to be made on a quarterly basis, yet local councils often do not receive the transfer amount, and/or transfers are often delayed, which impacts the implementation of key activities. There are also management challenges at the point of service delivery. Hospitals are late in submitting their expenditure reports, which impacts the timing of transfers (World Bank, 2021c). In education service delivery, the true spirit of decentralization is yet to be realized. While local councils receive funds for non-salary recurrent education expenditures, the major share of education expenditures (salaries, learning materials, school subsidies, and examination fees) are still under the control of the MBSSE. The MBSSE also maintains a presence at the district level with staff in the District Education Office, TSC, and the FQSE initiative. No legal or policy document outlines the specific roles and mandates of these various actors in relation to each other. This creates a situation where overlapping mandates lead to inefficiencies in service delivery. For example, the District Education Office, TSC, and FQSE all have mandates to monitor teacher quality and training. Corruption is prevalent at different levels of the system. Research shows that one in four survey respondents in Sierra Leone feel that at least some civil servants are engaged in some form of corruption. This figure is slightly higher for perceptions of corruption of local government council officials. The issue of corruption is pervasive in both the health and education sectors. According to the Afro Barometer Survey (2020), 50 percent of respondents said they had to pay a bribe, give a gift or do a favor to get the health care they needed. This was particularly true for poor respondents (64 percent) and respondents with no formal education (61 percent). Thirty-three percent of respondents claimed they had to pay a bribe to obtain public school services52. HCR focus group discussions with students revealed that offering bribes and exam malpractice has become normalized, such that some students stop pushing themselves to study because they believe they can rely on a bribe (in the form of money or sex). Other examples of corrupt practices in the education sector include exploiting child labor; teachers and school leaders getting jobs using fake results/ credentials and/or through nepotism; and school leaders, mission heads, and other community leaders creaming off significant portions of the Government subsidies so that schools lack the basic resources they need to pay community teachers, undertake basic repairs and maintenance or buy teaching and learning 52 According to the IGR (2021), only 49 percent of respondents reported having paid no bribe to access FQSE materials. Sierra Leone Human Capital Review 104 materials (GoSL, 2022). Given the widespread prevalence of corruption, the MBSSE has included eliminating corruption as one of its nine core objectives in the Education Sector Plan 2022–2026. Fragmentation and limited coordination and communication between bodies within each sector present considerable challenges for the efficient use of resources and coherent programming. The education sector illustrates the point well. Some agencies and sub-sectoral bodies have gaps in their mandates, overlapping mandates, or a lack of clarity on the reach of their mandates. These challenges are compounded by the lack of a forum for official bodies to meet to discuss key issues and clashes. One example is the six bodies directly involved in pre-service teacher education: the TSC, the MTHE, the MBSSE, The Tertiary Education Commission (TEC), The National Commission for Technical and Vocational Awards (NCTVA), and the Teacher Training Institutes. There is no forum for these bodies to meet and address key issues together, or even coordinate their calendars. There is an immediate opportunity for improved efficiency and coordination of resources by simply ensuring that issues over workforce pipelining, training calendars, and curricula are discussed in regular meetings together. This is just one example, but similar concerns can be found in other areas of the education sector’s work and, for that matter, in most other sectors. 4.3 Financing Low levels of financing inhibit investments in human capital interventions. Details on Government spending on human capital are presented in Chapter 2. Government expenditure on the human capital sector has increased over time. However, human capital outcomes are very low. A financial gap still exists, which prevents from fulfilling the country’s development strategies and improving human capital outcomes. Low capital expenditure has negative consequences for the performance of education and health service delivery. Personnel emoluments dominate public expenditures, which crowd out spending for goods and services. Imbalanced Government budget allocation within the sector needs to be corrected, and focus should be given to key areas and interventions that have proven effective. There is a lack of effective governance and management systems. Monitoring and evaluation of resources against services provided need to be strengthened. It is important to prioritize spending on human capital to improve the efficiency and quality of services. In the medium and longer term, overall financing on human capital needs to be increased toward achieving universal health coverage and universal education access. 4.4 Food Insecurity The prevalence of food insecurity in Sierra Leone is very high. Overall, Sierra Leone’s food insecurity has increased from 45 percent in 2010 to 57 percent in 2020 (WFP, 2021). Hunger level in the country was categorized as serious in the 2022 Global Hunger Index53, ranking 112th out of 121 countries. The number of people facing severe hunger has tripled between 2010 and 2020. The main cause of food insecurity is the lack of access to nutritionally diverse foods, with 85 percent of children between 24–59 months not consuming diets that meet minimum dietary diversity requirements. The lack of dietary diversity is due to several factors, including outdated agricultural methods, insufficient and expensive agricultural inputs impacting yields, high harvest losses, uneconomic access to markets, and high food prices (WFP, 2021). Food insecurity contributes to poor nutrition, health, education, and employment outcomes. Food insecurity is associated with poor well-being and adverse health outcomes, including increased exposure to chronic diseases (Food Research and Action Center, 2017; Gregory and Coleman-Jensen, 2017; Laraia, 2013; Seligman et al., 2010; Terrell and Vargas, 2009), and malnutrition (Moradi et al., 2019). Household food insecurity is correlated with child stunting (Gassara and Chen, 2021; Mahmudiono et al., 2018; Singh et al., 2014), and the link between stunting and learning for children generally indicates poorer performance in the learning space. Beyond its association with poor performance in schooling, which tends to be observed in children as a medium-term consequence, the effect of stunting on reducing earning potential in adulthood 53 The Global Hunger Index (GHI) is a composite measure of child stunting, child wasting, child mortality, and undernourishment at the population level that tracks and compares hunger level across countries and regions. 105 Chapter 4 - Drivers of (or Challenges to) Human Capital Formation has been observed in many settings. Understanding the potential loss of earnings as a long-term effect is significant because it provides a basis for understanding the aggregate cost of childhood malnutrition to human capital development and what society stands to gain in social and economic returns from investing in infant and childhood feeding and nutrition. In the long term, stunting lowers income levels in adulthood because of its contribution to cognitive impairment, slow physical growth in early life, increased vulnerability to chronic diseases, and lower educational attainment (Akseer et al., 2022; Hoddinott et al., 2013). Estimates by Galasso and Wagstaff (2019) show that stunting in childhood reduces per capita income for the workforce in SSA by as much as 9 percent. On the other hand, there is a strong investment case for interventions that reduce stunting because of its effect on increasing earnings in adulthood (Hoddinott et al., 2013; McGovern et al., 2017). Food insecurity is also associated with an increased risk of preterm birth. The evidence indicates that pregnant women from food-insecure households are at higher risk of experiencing preterm births to babies small for gestational age (Richterman et al., 2020; Zar et al., 2019). The implication of preterm birth as one of the major causes of newborn mortality is well established (Desta et al., 2021; Kannaujiya et al., 2022;). Photo: © Dominic Chavez / World Bank Sierra Leone Human Capital Review 106 4.5 Gender Women in Sierra Leone continue to face barriers usually beyond those faced by men, which inhibit their access to employment, education, political participation, and their capacity to invest in human capital. In addition to the widespread sexual violence against women during the decade-long civil war, GBV, discrimination, and challenging social norms are some of the barriers women continue to face. As of 2021, Sierra Leone was ranked 162 out of 170 countries on the UNDP’s Gender Inequality Index with a score of 0.63, which is higher than the SSA average of 0.57 (UNDP, 2022). The index reports gender-based disadvantage in three dimensions: reproductive health, empowerment, and labor market. It highlights the loss in potential human development due to inequality in outcomes between women and men in these dimensions. The high prevalence of gender inequalities in social institutions like family, education, government, and marriage manifests in the low decision-making power of women within households, sexual abuse of women in institutions, and high incidence and acceptance of GBV against women. The institutionalization of discrimination leads to persistent lower human capital outcomes for women and girls. Therefore, investment in women’s empowerment should be targeted to reduce power asymmetry between women and men in these social institutions. Although advancements in protecting women and children have been made in the legal framework, the lack of harmonization between national and customary law impedes further improvements. Sierra Leone has made improvements to protect women and children from exploitation by ratifying the Convention on the Rights of the Child in 1990, which sets a minimum age of marriage at 18, and the Convention on the Elimination of All Forms of Discrimination Against Women in 1988, which obligates states to ensure free and full consent to marriage. However, national legal inconsistencies and weak enforcement of the legal framework that has been established to protect young girls are exacerbating adverse social norms and exposing young girls to significant risks. This is particularly the case for child marriage, with many rural communities respecting customary leadership and bylaws more than national law. Most notably, the Child Rights Act (2007) prohibits marriage for anyone under the age of 18, but it is undermined by the Customary Marriage Act (2007), which allows marriage under 18 with parental consent. Reforms to the latter are required to ensure compliance with the Child Rights Act and to reduce the health risks associated with pregnancies among adolescent girls. Education is key in lifting people out of poverty, improving livelihoods and health outcomes, and social advancements. Education provides a vital channel through which women can be empowered. Although the gender gap in education outcomes has been reducing in Sierra Leone, there remain inequalities between boys and girls. For example, primary school enrollment rates are similar for boys and girls, yet lower transition rates to senior secondary school persist for girls. Results from the SLIHS 2018 cite pregnancy or marriage as the most common reason for girls dropping out of school, accounting for 36 percent (World Bank, 2022a). Furthermore, the gap between women and men in adult literacy is 15 percent, higher than the SSA average (13 percent). These inequalities in education outcomes also manifest in employment outcomes for women. The 2019 DHS report highlights that men (72 percent) are more likely than women to be employed (69 percent). More women are employed in the agriculture sector and are less likely to be employed in professional, technical, managerial jobs and skilled manual labor. This is likely linked to the lower education attainment levels of women. Early marriage and higher school dropout rates amongst women, lack of reproductive health knowledge, and lack of youth-friendly health services also contribute to high adolescent fertility rates. Results from the 2019 DHS report that the median age at first marriage amongst women aged 20–49 is 19.8 years and that women generally marry earlier than men (DHS, 2019). The adolescent fertility rate is 105 births per 1,000 women aged 15–19, higher than the SSA average of 98 births per 1,000 women. Results from the DHS also indicate that girls with secondary and higher education start childbearing later than those with no education. Adolescent pregnancy not only poses challenges for young girls in terms of disruptions in schooling and social stigma, but they also have higher health risks than adult mothers, leading to maternal mortality, low birth weight, and other neonatal conditions. 107 Chapter 4 - Drivers of (or Challenges to) Human Capital Formation Girls and women are often subject to sexual exploitation and violence. As girls try to secure financial support to fund their education, some have reported feeling pressured or coerced into sex in return for financial support. These arrangements often lead to girls dropping out of school as they end up getting pregnant (Human Rights Watch, 2023). This was also highlighted as a major issue in the HCR focus group discussions with university students. Girls and women are also susceptible to violence as 62 percent of women aged between 15 and 49 have reported having experienced physical or sexual violence (SLIHS, 2019). In a report of out-of-school girls, one in four girls reported that they experienced rape as a form of violence in their community, and 60 percent of girls agree that women should accept violence in the home to keep the family together (We are Purposeful, 2022). There have been some steps taken to strengthen action against GBV. For example, in 2019, the amendment of the 2012 Sexual Offense Act increased the maximum sentence for rape to life imprisonment, codified offenses for assaults by people in authority, and criminalized the attempt to settle GBV cases without reporting to authorities. According to the 2020 Afrobarometer survey, 89 percent of people believe the harsher punishment will reduce sexual offenses against women, although 71 percent do not believe that these laws alone will be enough to solve the issue of high GBV cases. Rather, the Government should make significant efforts to educate people and change sexual attitudes and behavior. These advancements in policies to promote gender equality are essential for women’s economic and social empowerment and their human capital outcomes. The use of the services and systems established by the laws should be monitored to assess effectiveness. In addition, these inequalities are deeply rooted in society and are usually a consequence of social norms. Therefore, intensive education and behavioral change campaigns will also be key. Another important factor in improving outcomes for women is ensuring greater representation of women in various spheres of society. To address this, the Gender Equality and Women Empowerment Act (2021) was established, which makes a provision for a minimum of 30 percent quota for cabinet and parliament representation of women, as well as employment in private companies with 25 or more employees. 4.6 Disability and Inclusion Persons with disabilities are amongst the most marginalized and vulnerable in Sierra Leone. Data from the 2018 SLIHS reports that 4.3 percent of the population are persons with disabilities, with an equal share of men and women. Women with disabilities are more disadvantaged than men with disabilities as they suffer the double impacts of disability and gender inequality and are more vulnerable to abuse, exploitation, and GBV. Poverty amongst persons with disabilities in Sierra Leone persists due to the constraints in accessing education, employment, health services, and sanitation. Seventy percent of persons with disabilities are in rural areas, which in Sierra Leone typically have limited access to schools, health clinics, electricity, and other basic services essential for human capital development. Even persons with disabilities in urban areas face challenges with housing with limited access to sanitation, water, and information. People with disabilities are more likely to have never attended school (67 percent) compared to persons without disabilities (42 percent), and even those that are enrolled in school are usually inadequately catered for in terms of the school environment as well as teaching and learning resources (MICS, 2017). In the 15 to 64 age bracket, persons with disabilities are also less likely to be engaged in the workforce (57.8 percent) than persons without disabilities (63.1 percent), which further reduces resilience to shocks and their capacity to invest in human capital development. In addition, 30 percent of youth with disabilities are NEET, significantly higher than the national average of 23 percent. Over the last decade, Sierra Leone has made progress in the inclusion of persons with disabilities in terms of the establishment of policies and programming. The Persons with Disability Act, enacted in 2011, aims to prohibit discrimination against persons with disabilities and achieve equalization of opportunities. In the education sector, the National Policy on Radical Inclusion in Schools was established in 2021 to ensure that schools are accessible to and inclusive of marginalized groups, including children with disabilities. The Government has also demonstrated prioritization of persons with disabilities in social protection programs. For example, the Government’s cash transfer program, Ep Fet Po, aims for at least 25 percent of beneficiary households to include persons with disabilities. Each household with a person with a disability receives an additional one-off payment. As of 2022, the Program has exceeded this target with 35 percent of beneficiary households with persons with disabilities. Additionally, during the COVID-19 pandemic, the Government Sierra Leone Human Capital Review 108 funded one-off cash transfers and in-kind commodities to persons with disabilities to cushion the economic impacts of the pandemic. As the rates of disability and illness usually increase with age, the Government also established a social pension program, Social Safety Net Program for the Vulnerable Aged, to support the poor elderly with cash transfers. However, due to insufficient funding, the transfers to beneficiaries were ad hoc and decreased over time. For further progress on the Government’s reach to persons with disabilities, it is important to implement programs and strategies that consider the specific barriers that persons with disabilities face in accessing education, employment, healthcare, and other basic services that contribute to human capital accumulation. To a large extent, this can be facilitated by the availability of relevant and comprehensive data on persons with disabilities for more insight into the demographics and specific needs of persons with disabilities. In terms of education, teaching facilities lack inclusive teaching practices and support facilities to encourage the enrollment of children with disabilities. Addressing such issues of accessibility within the education sector can help narrow the participation gap between children with and without disabilities. Persons with disabilities are usually burdened with additional expenses to access education, healthcare, employment, and other forms of livelihood, therefore social assistance programs are extremely relevant for this population group. The consistency and adequacy of funding of programs targeting persons with disabilities are paramount to increasing the capacity of this group to invest in human capital development. 4.7 Social Norms Prevailing social norms and cultural practices are contributing to multiple human capital issues. Evidence suggests that cultural and social norms can sometimes hinder national and individual development (World Bank, 2015). For instance, some cultural practices and social norms create discrimination and perpetuate against women and persons with disabilities. Research shows that in Sierra Leone, women have limited decision-making power at all levels – household, community, and national – and even on matters directly related to their life, health, and welfare, including whether to have sex, use contraception, or marry (Secure Livelihoods Research Consortium, 2021). Women and girls are expected to take care of domestic tasks and be primary caregivers to the family. It is often believed that women and girls should come after men and boys in accessing healthcare, education, and food (Heise and Manji, 2016). Gender-based violence is rooted in such unequal power relations between women and men. Gender norms contributing to gender inequality underpin constraints toward the utilization of women and girls and thus negatively affect human capital accumulation. Discriminatory social norms and social stigma also constrain the capacity of people with disabilities to participate in society effectively. Women with disabilities face double discrimination based on their gender and disability. Addressing these negative attitudes and discriminatory social norms is essential for accelerating human capital development. Social norms and negative attitudes can change either with a top-down (e.g., driven by economic development, new laws, and policies, etc.) or a bottom-up approach (e.g., when groups and individuals see some norms as problematic and act to change them). In the former, policymakers play an important role. Key elements of successful norm change using a bottom-up approach include: a. Working with leaders and/or champions whose opinions matter most on a particular issue. b. Finding early adopters of new norms and making their behaviour visible to others. c. Providing opportunities for people to practice new behaviour and creating new rewards and sanctions. d. Facilitating communication, advocacy, and awareness campaigns. 109 Chapter 4 - Drivers of (or Challenges to) Human Capital Formation 4.8 Digital Economy and Innovation Leveraging digital technology can accelerate economic growth. In the past decade, digital technology and innovation have transformed how we work, live, interact, and even govern our societies. Digital technologies have now become critical drivers of development, providing new and creative solutions to accelerate growth and create productive employment opportunities. According to a 2020 research paper by the Global System for Global System for Mobile communications Association (GSMA), mobile technology significantly increased GDP between 2000 and 2017 – a 10 percent increase in mobile adoption boosted GDP by 0.5 percent to 1.2 percent (Ariza and Bahia, 2023). In 2016, the World Bank estimated that the global digital economy was worth about US$11.5 trillion, equivalent to 15.5 percent of the world’s overall GDP, and this is expected to increase in the coming decades (World Bank, 2020d). The digital economy offers immense benefits to individuals, businesses, and the economy. For individuals, it can lower the cost of services by increasing market competition and enabling consumers to access a wider array of quality products and services. For firms, it can drive productive efficiency, lower the cost of operations, and improve business processes. Digitalization can improve governance systems for governments and encourage transparency and accountability across all levels. Finally, for the wider economy, it can help correct market failures by effectively connecting buyers and sellers, opening new pathways for generating jobs, leapfrogging development, and improving the lives and livelihoods of the entire populace. Even across specific sectors such as health and education, technology-driven solutions are critical in solving pertinent problems and bridging the existing gaps. Box 7. Key Pillars for Creating an Enabling Environment for the Digital Economy To fully reap the benefits of the digital economy, key pillars must be present in creating an enabling and conducive environment. These digital economy pillars are critical in ensuring inclusive and sustainable growth in the digital and real economy. According to the World Bank Diagnostics Report for Sierra Leone, these pillars include: • Digital platforms. This covers the different services and products made accessible to consumers via digital channels, such as mobile devices, tablets, computers, and the internet. Digital platforms encompass all aspects of life, from social media and government to commercial activities. • Digital infrastructure. This provides a medium for consumers, businesses, and governments to access digital products and services. It encompasses everything from mobile phones to internet connectivity and even electricity. In the absence of adequate digital infrastructure, the existence and sustainability of the digital economy is threatened. • Digital regulation. While the benefits of digital technology cannot be denied, they also pose new and peculiar challenges for regulators and national governments. For instance, the nature of the digital economy has raised concerns about consumer protection, data privacy, cybersecurity, etc. For digital technologies to succeed, the policy and regulatory framework must be conducive and adaptable to the fast-paced nature of technological change and innovation. Sierra Leone Human Capital Review 110 • Digital literacy and skills. This refers to the development of a population equipped with the basic skills and knowledge necessary to take advantage of modern technologies. It is a fundamental building block of the digital economy because, without digital literacy, the full benefits of these innovations cannot be harnessed. • Digital entrepreneurship. This refers to the firms and businesses that leverage digital platforms to deliver their products and services to users. • Digital financial services. This refers to the broad range of financial services and products accessed and delivered through digital platforms/channels. It includes digital payments, credit, insurance, savings, etc. Digital financial services are revolutionizing the financial system across the continent and the world at large in a bid to address the inefficiencies of brick-and-mortar banks and improve the consumer experience. Digital financial services can accelerate growth and productivity through various channels, such as access to credit, wealth management, and insurance against shocks. Like its regional counterparts, Sierra Leone is well placed to fully harness the benefits of digital technology and innovation in solving some of the nation’s most pressing issues. During the Ebola crisis in 2014, the country witnessed firsthand the transformative effect of digital technology, specifically mobile phones, in tracking, monitoring, and curbing the spread of the disease. Likewise, during the COVID-19 pandemic, digital technology once again proved useful in curbing the spread of the virus and cushioning the concomitant shocks to the economy. In 2018, the Government established the Directorate of Science, Technology, and Innovation (DSTI) in the Office of the President. The core mandate of DSTI’s vision is to use science, technology, and innovation to help the Government deliver on its MTNDP and to establish Sierra Leone as an ‘Innovation Nation’. A year later, the Government developed a 10-year National Innovation and Digital Strategy (2019–2029) to create a robust and sustainable framework to guide the country’s digital economy. The strategy document articulates a vision in which the digital economy drives effective service delivery and citizen engagement, lowers the cost of governance and corruption, and increases national productivity. Despite these notable developments in the digital economy, challenges remain. Most citizens still lack access to digital infrastructure. Even across key indicators for Information and Communication Technologies (ICT) performance, such as data protection, consumer protection, and regulatory capacity, Sierra Leone lags behind its regional counterparts. Digital technology can play an important role in developing innovative solutions to tackle human capital challenges. For example, digital solutions can be leveraged in health to lower the cost of care, expand access to health services, and improve the distribution and delivery of services across the health value chain. An example is Ghana’s MPharma, which aims to improve access to healthcare financing by providing inventory management solutions to patients, pharmacies, and hospitals. Their business model lowers the cost of pharmaceutical products by aggregating and predicting demand. This is just one of many examples of how technology can revolutionize healthcare provision and delivery. In education, technology can be leveraged to improve learning outcomes. For instance, Nigeria’s ULesson app is helping secondary students across the continent get better grades by creating a more engaging learning experience. With recent developments in Artificial Intelligence (AI), developers have launched AI-based teachers’ assistants and tutors to facilitate learning in the classroom (e.g., Khan Academy’s KhanMigo). Similarly, digitization in agriculture can offer enormous potential in transforming agri-food systems, and it can strengthen farmers’ linkages to input markets, output markets, and credit. For example, Twiga, the Kenya-based AgriTech, is creating robust and efficient supply chains through technology-driven solutions. 111 Chapter 4 - Drivers of (or Challenges to) Human Capital Formation 4.9 Climate Change Climate change poses a significant challenge to building human capital in Sierra Leone. Floods, sea level rise, landslides, droughts, deforestation, and wildfires have frequently hit Sierra Leone since 1996, affecting the population and hampering human capital accumulation. Due to topographical variations, Sierra Leone’s tropical climate is predominantly hot and humid, with temperatures increasing and precipitation decreasing moving inland from the coast. The mean annual temperature of Sierra Leone falls within the range of 25– 28°C and has risen by 0.8°C over the last fifty years, with an acceleration in recent years. As temperatures continue to rise, extreme temperature conditions will become normality for the people of Sierra Leone, as seen in Figure 4.1. Figure 4.1 Projected Mean Temperature Source: World Bank, Climate Change Knowledge Portal. Sierra Leone is ranked among the top countries most vulnerable to the negative impacts of climate change, and the education and health sectors are particularly vulnerable. Prolonged exposure to extreme heat in the classroom is likely to cause heat-related illnesses and discomfort, leading to missed school days and lower learning outcomes, especially for young children. Higher temperatures and flooding also facilitate the proliferation of water-borne bacteria such as typhoid and cholera, which remain a significant public health concern in Sierra Leone with the consumption of contaminated drinking water, inadequate sanitation facilities, and poor hygiene practices (GoSL, 2019). Floods exacerbate mosquito breeding environments such as moisture and standing water, including the mosquitos responsible for transmitting malaria, a leading cause of death among Sierra Leoneans. The overflow of rain also triggered the Mount Sugarloaf landslide in 2017, which directly impacted hundreds of children’s lives and resulted in over 1,100 fatalities. This was one of the most devastating natural disasters on the African continent, and as rainfalls are expected to intensify, landslide risk is projected to increase in Freetown and interior mountainous areas. Such an event not only increases the burden on an already fragile healthcare system due to a sudden surge in hospitalizations, but also undermines educational and health facilities by directly damaging their infrastructure or impeding access. Sierra Leone Human Capital Review 112 Climate change is likely to affect people’s ability to access enough food, which could impact their livelihoods. Like water abundance, water scarcity can be a major challenge to human capital accumulation as drought conditions often force the population to use contaminated water sources. Moreover, droughts disrupt agricultural activities, including rice cultivation. The shortage of water resources affecting the development of rice, a staple food for Sierra Leoneans regardless of their economic status, combined with the increasing prices of imported rice, is likely to create a significant challenge to food security in the country (WFP, 2021). As discussed in Chapter 3, Sierra Leone’s economy relies heavily on its agricultural sector. The agricultural sector is vulnerable to climate change impacts, such as extreme weather events, changing weather patterns, and rising temperatures, affecting crop yields, soil fertility, and water availability. Adaptation measures such as promoting organic farming, improving the seed sector, and, to a greater extent, adopting climate-smart agriculture are crucial to addressing the changing demands of the sector and creating new opportunities for workers in these areas. Providing training and education to agricultural workers will help the sector adapt to the changing climate and provide sustainable employment opportunities for workers in Sierra Leone. Green skills primarily involve practical and technological knowledge, particularly in engineering, with a reliance on experience and heuristics. To transition to climate-smart agriculture practices, farmers will need training in topics such as pest and disease management, crop management, tree management, soil management, and water harvesting and management. In addition, digital skills will be required, including climate information services, digitization of farm records, and early-warning pest and disease management systems. Other updated and advanced skills in research, soil science, pathology, plant cultivation and animal breeding will also be required. New occupations requiring interdisciplinary skills, such as agricultural meteorology, will also be in demand due to climate change’s impact on weather patterns (ILO, 2011). The Government has been demonstrating a keen interest in developing a green economy agenda, as evidenced by various points in Sierra Leone’s MTNDP 2019–2023. Goal 1 of the plan is to build ‘A diversified, resilient green economy,’ recognizing the importance of establishing a stable and predictable policy environment that supports private sector growth, economic diversification, job creation, and poverty reduction. Additionally, Cluster 7 of the national strategy highlights the need to build a resilient and inclusive society that can withstand shocks to achieve sustainable development. 4.10 Pandemic and Resilience to Shocks Sierra Leone has been through two major pandemics in the last two decades: Ebola virus disease and COVID-19. In 2020, in the education sector, the Government overturned a 10-year ban on pregnant girls attending school in anticipation of school closure and the impact this may have on girls. The MBSSE established an Education Emergency Taskforce to mitigate the impact of COVID-19 on children and learning. One of the measures taken by the MBSSE in collaboration with the TSC was to revive the radio teaching program, which was created during the Ebola virus disease, to ensure learning continuity during school closures. The MBSSE has a dedicated radio station for this initiative. In terms of school preparedness for COVID-19, the MBSSE took various measures. On COVID preparedness, a training program was rolled out across the country prior to the reopening of schools. Instructions were given to ensure that all students and staff wore face masks and regularly washed their hands, and the school assembly was suspended to prevent the gathering of students. The 2020 Service Delivery Index evaluated the school preparedness for COVID-19 across four dimensions: (a) the existence of COVID protocols; (b) the number of trained teachers in COVID preparedness; (c) availability of water in the toilet facility; and (d) compliance with COVID protocols in schools. Overall, it was assessed that 60 percent of schools were adequately prepared for COVID, with the highest level of school preparedness in Freetown, Pujehun, and Bo (IGR, 2021). In the health sector, the Government, working with partners, implemented several interventions to mitigate the impact of COVID-19. Critical actions taken by the Government in response to the COVID-19 pandemic included the establishment of an inter-ministerial committee to guide on policy issues, identification of major points of entry with the highest risk of COVID-19 transmission (i.e., Freetown International Airport, and major border crossing points with Guinea and Liberia). These efforts boosted diagnostic capacity at three public health laboratories with linkages established with South Africa and the United States, strengthening risk 113 Chapter 4 - Drivers of (or Challenges to) Human Capital Formation communications and trainings, and ensuring availability of supplies at strategic locations (WHO, 2020b). According to IGR (2012), 62 percent of respondents reported personal protective equipment availability, while 80 percent reported the availability of COVID-19 trainings and protocols. Yet, the pandemics have had broader impacts on Government spending, which are likely to impact human development sectors. For example, the negative impact of the Ebola virus disease was associated with a reduction in Government capital expenditures post-pandemic (Kum et al., 2019). Photo: © Moses Alex Kargbo / World Bank Sierra Leone needs to take transformative action to build stronger, more resilient systems in basic ser- vices that can better prevent, prepare for, and respond to future shocks and emergencies. Sierra Leone remains fragile, with risks of weak capacity, challenging environments, and vulnerability to multidimensional shocks (for example, epidemic/pandemic, economic, and climatic). The country’s experience shows that such shocks disproportionately affect poor and vulnerable households. In order to be resilient to future shocks, crisis and risk management needs to be institutionalized in the country’s systems by having a crisis and risk management policy, a dedicated team of Government staff that is tasked with developing and implement- ing such policies, and strong coordination mechanisms using multi-sectoral approaches, at all levels of the system (UNESCO, 2021). Sierra Leone Human Capital Review 114 Adaptive social protection systems provide effective means to build the resilience of poor and vulnerable households during crises and shocks. These events usually disproportionately affect poor and vulnerable households, which forces reliance on negative coping strategies. In Sierra Leone, the social safety net systems built for targeting, payment and citizens’ engagement were leveraged to provide support to affected citizens during climate, health and economic shocks. It is essential that further investments are made in strengthening the shock-responsive social protection systems to provide timely, scalable and well-targeted social interventions during crises. These investments can be channeled through: (a) programs; (b) data and information systems; (c) finance; and (d) institutional arrangements and partnerships (Bowen et al., 2020). a. Programs. Given the high poverty rates, the Government should strengthen the overall social protection system and expand coverage, which will provide more avenues for reaching poor and vulnerable households with assistance before and after shocks. Similar to non-governmental partners, the Government has launched several social protection programs to boost human capital development amongst the most vulnerable in the country. There are significant opportunities to improve the targeting and efficacy of social protection, by addressing the fragmentation of spending across several small programs and consolidating some of these into bigger programs with better targeting and coverage. b. Data and Information. The social protection information system developed under the World Bank-financed Social Safety Net Project, namely the Social Protection Registry for Integrated National Targeting (SPRINT), aims to consolidate information on both beneficiaries and potentially eligible households to assist the Government in the targeting and coordination of social protection interventions in Sierra Leone. SPRINT delivers the functionality and services associated with a social registry. Expanding the coverage of SPRINT across social protection programs in health and education will promote integration and interoperability of information and delivery systems across Social Protection programs. It is also vital that the SPRINT/social registry is dynamic and that data is frequently updated to be useful in assessing households’ or individuals’ vulnerability to shocks for effective targeting of crises response. The integration of information systems will also facilitate new programs to leverage existing capability and enable existing programs to scale up/ expand (including for shock responsive and adaptive social protection). c. Finance. There is currently limited financing of social protection and risk-financing mechanisms in use in Sierra Leone. Disaster response is ad hoc and mostly funded by donors. Several relevant documents already exist exploring Disaster Risk Financing (DRF) in the context of Sierra Leone, but options have not been implemented. Application of some of these options, outlined in Chapter 5, can provide more fiscal space for shock-responsive social services that can protect human capital during crises. d. Institutional arrangements and partnerships. The need for strong cross-sector coordination and collaborations is embedded in each of the building blocks described above. Policy and strategy coherence creates the blueprint for collaborations that effectively provide shock-responsive systems. Coordination amongst human development sectors must be strengthened to improve efficacy of programs, especially during crises. 115 Chapter 4 - Drivers of (or Challenges to) Human Capital Formation Box 8. The Impact of COVID-19 on Sierra Leone’s Health Sector The COVID-19 pandemic led to huge interruptions to daily life and presented many challenges for the country’s healthcare system. In April 2020, the country published its first case management guidelines, which saw all elective surgery postponed, creating extra bed capacity and reducing opportunities for transmission. This policy is undoubtedly responsible for some of the reduction in elective procedures in the following months. As shown in Figure B.4.1, access to a host of health services fell after August 2020 and has remained low since. Most notably, institutional deliveries and new family planning visits have fallen almost 50 percent below expected (pre-pandemic) levels. New outpatient visits have also fallen by around 15 percent. Ahmad et al. (2022) examine the impact of service disruptions on child, neonatal, and maternal mortality. They estimate the absolute number of additional deaths in Sierra Leone from March 2020 to June 2021 to be 2,296 child deaths (0 to 59 months), 561 neonatal deaths (<1 month), and 32 maternal deaths. This is equivalent to a 6.4 percent, 4.4 percent, and 0.7 percent increase in child, neonatal and maternal deaths, respectively, over this period. Figure B.4.1 Shortfall in Service Delivery Compared to Pre-Pandemic Levels Source: Global Finance Facility Data Portal (2023). Sierra Leone Human Capital Review 116 Chapter 5 Human Capital in Sierra Leone: The Way Forward This chapter summarizes the main findings and presents related strategic priorities and policy recommendations to improve human capital outcomes for Sierra Leone. The chapter focuses on the core issues of (a) improving learning outcomes; (b) addressing child mortality and malnutrition; (c) maternal mortality and reproductive health; and (d) enhancing the employability of youth. It also presents priorities and policy recommendations in cross-cutting areas. Photo: © Moses Alex Kargbo / World Bank 5.1 Strategic Actions and Policy Recommendations in Core Human Capital Sectors Prioritizing investments in high-impact interventions54 – in education, these are activities focused on improving foundational learning and enhancing youth employability; in health, improving access to essential obstetric and neonatal care, and improving the availability of youth-friendly family planning services. (See details below.) Education Key interventions to improve foundational learning are as follows (see Box 9): • Increase access to schooling, particularly at the early childhood and secondary education levels. This could involve engaging in public–private partnerships where Government schools may not be available and constructing/upgrading schools (particularly at the early childhood education level), but using the School Catchment Area Policy Guidelines and tools that have been developed utilizing data to identify localities where need is greatest. • Pay special attention to addressing disparities in access to quality education and promoting gender equality and inclusive education, and focus on the implementation of the National Policy on Radical Inclusion. Identify vulnerable groups such as children with disabilities, OOSC, and pregnant girls, and provide the necessary support, working closely with key stakeholders such as other Government agencies, school management committees, community leaders, social workers, etc. • Prioritize learning and improve the quality of teaching and learning by focusing on structured pedagogy, teacher mentoring, student assessment, and quality teaching and learning materials. Box 9. Government’s Ongoing Effort to Improve the Quality of Learning Prioritize investments in high-impact interventions in education • The MBSSE is implementing structured pedagogy based on updated teaching and learning materials in pre-primary and grades 1–4 for literacy, numeracy, and civics, and applying in-person and digital teacher mentoring. Reduce households’ out-of-pocket expenditures for health and education to improve access • The FQSE Program removed school and exam fees while investing in furniture, teaching and learning materials, as well as other support for students Leverage technology to improve health and education service delivery • One example is the MBSSE’s results-checker, which grants instant access to exam results and school placement. 54 Non-exhaustive list. 118 Chapter 5 - Human Capital in Sierra Leone: The Way Forward Ensure human capital interventions are targeted to vulnerable groups • Sierra Leone Education Innovation Challenge offers a premium for improving learning outcomes for girls. • National Policy on Radical Inclusion in Schools particularly focuses on pregnant girls and parent learners, disabled students, and students from poor and/or geographically remote backgrounds. Youth Skills and Employability High-impact interventions to enhance youth skills and employability would include: • Improve the quality and relevance of TVET and higher education sectors. More youth need to be better educated and equipped with the necessary competencies and skills needed in the labor market. • Re-align skills training course offerings to those for which there is demonstrated demand from the labor market (See Box 10). Prioritize digital skills (basic and intermediate level). • Strengthen partnerships with industry to increase involvement in skills training (e.g., curriculum development, training, assessment of students, on-the-job training, and job placement). • For rural youth, who are mainly employed in agriculture, provide complementary services such as basic digital and financial literacy, start-up grants, and linkages to Government services through economic inclusion programs. • Reform/formalize the apprenticeship model (See Box 11). • Provide support (in the form of training, some capital/start-up kits, etc.) to individuals to establish their own enterprises or scale up their businesses. • For female employability, employers should be incentivized to provide on-the-job training opportunities, particularly for women. Women should have increased opportunities to access credit for their enterprises, and there should be strict enforcement of the Gender Equality and Women’s Empowerment (GEWE) Act (2022), which introduces a 30 percent quota for women in public and private sector jobs, 14 weeks of maternity leave, and guaranteed equal pay. Enhancing access to affordable childcare services is also essential to improve labor market outcomes for women, and one approach could be establishing community-based childcare centers to alleviate the burden of unpaid care work on women, enabling them to participate in the labor market. • Collect more regular data on labor market outcomes for youth to inform labor market policy and youth employment interventions. Sierra Leone Human Capital Review 119 Box 10. Strengthening Skills Acquisition Strengthening skills acquisition by improving the quality and relevance of training and capacity-building programs is important. The Government needs to scale up efforts to increase the availability of training and vocational programs for young people. This can be achieved through industry internship and apprenticeship programs in collaboration with the private sector to help tackle the skills mismatch problem. The Government, specifically the MTHE, has taken some positive steps. Through the National Council for Technical and Vocational Award (NCTVA), competency-based curricula for 25 priority occupations have been developed and will be rolled out. This marks a significant departure from the previous method of training, which was largely theory-based with limited opportunities for practical training and assessing students’ competencies (that is the application of knowledge). In addition, the MTHE is developing important policies that are expected to improve the quality and relevance of training, including developing a National Vocational Qualification Framework (NVQF) and a Dual Apprenticeship Policy55. Through the World Bank-financed Skills Development Project, the MTHE has also implemented a demand-led skills training model whereby public and private training providers and businesses apply for funding to train individuals in priority sectors. This model has benefitted approximately 20,000 young Sierra Leoneans, and the overall response from beneficiaries has been very positive. Moving forward, strengthening the quality and relevance of skills training in Sierra Leone could involve the following: • Improving the alignment between labor market supply and demand by establishing sector skills bodies. These bodies would facilitate dialogue between the private sector and the Government on matters related to TVET/Higher Education and the labor market. • Reprioritize investments in skills training based on evidence and labor market needs. In addition to the information from employers regarding anticipated vacancies and potential growth occupations, there is a need to utilize information from tracer studies to assess which courses are leading to greater employment outcomes and which courses are contributing to the oversupply of labor. Financing should then be reprioritized based on this assessment. • Further rolling out of the dual-apprenticeship system, based on the experience from the ongoing pilot activities, and strengthening of On-the-Job Training (OJT) for TVET and higher education students/graduates. • Establish incubation hubs occupational groups/cooperatives (at higher education and TVET institutions) and provide post-training support (e.g., materials, equipment, credit, mentorship, etc.) to high-performing graduates to set up/expand their own enterprises. • Expand support to the skills development fund to increase access to demand-led skills training. • Upgrade training facilities to ensure there are fully equipped centers for priority occupations. • Support the transition to climate-smart agriculture practices by training farmers on topics such as pest and disease management, crop management, tree management, soil management, and water harvesting and management. 55 The NVQF will classify qualifications by level based on learning outcomes. This will help improve mobility between different education subsystems and will help Sierra Leoneans looking to transition to international labor markets. The apprenticeship policy will help provide an opportunity for job seekers to gain practical work experience, encourage learners and employers to participate in the DAP, and provide skills training that will lead to recognized occupational qualifications. 120 Chapter 5 - Human Capital in Sierra Leone: The Way Forward Social Protection High-impact interventions in social protection would include: • Regularly collect and disseminate detailed and high-quality data on social assistance, social insurance, and labor market programs. • Strengthen social protection systems by improving targeting and efficacy and addressing the fragmentation of spending across several small programs – consolidating some of these into larger, better-targeted programs. • Continue strengthening and scaling up key social protection programs, including cash transfers, labor-intensive public works, and productive inclusion, especially to support the bottom 40 percent of the population, largely employed in subsistence agriculture. • Expand interventions that support informal sector workers, such as through pension and savings schemes designed for this profile of workers. • Invest in a social protection system that will allow interoperability with other national systems, such as the Civil Registry/ID Agency and the National Electronic Payment System, to optimize delivery and improve the efficiency of social protection services and delivery costs. • Expand the coverage of SPRINT to promote integration and interoperability of information and delivery systems across social protection programs in health and education and frequently update data. • Invest more in social protection, risk-financing mechanisms, and disaster response (See Box 11). Box 11. Ongoing Effort of Shock-Responsive Social Services under the World Bank-financed Social Safety Net Project Several relevant documents already explore social protection and disaster risk financing in the context of Sierra Leone. However, options have not been implemented. Application of some of these options can provide more fiscal space for shock-responsive social services that can protect human capital during crises. Some of the examples under the World Bank-financed project are presented below: • Investing in the operationalization of data-driven triggers developed under the project to augment the social safety nets’ responsiveness to climate shocks such as floods. • Leveraging investments in anticipatory action and the soon-to-be-launched disaster-risk financing strategy to position financing toward a social protection response following a disaster. • Creating fiscal space for social protection programming through, for example, prearranged risk financing with support from donors to enable rapid scale-up during shocks. Sierra Leone Human Capital Review 121 Health High-impact interventions in health would include: • Improve access to quality essential obstetric and neonatal care by prioritizing investments in areas where there are large, underserved communities. • Improve the functionality of Sierra Leone’s emergency referral system so that communities in less densely populated areas can access essential obstetric and neonatal care services. • Invest in sexual reproductive health education to improve adolescents’ awareness on sexual behaviors and empower them to make informed decisions. This includes accelerating and scaling up the training of teachers in Sierra Leone’s Comprehensive Sexual Education (CSE) curriculum, which has already been developed and piloted but not scaled nationally. • Increase youth-friendly family planning services to ensure the availability of family planning commodities and counselling for adolescents. Box 12. Government’s Interventions to Improve Access to Quality Essential Obstetric and Neonatal Care by Prioritizing Investments in Areas with Large, Underserved Communities The Government of Sierra Leone has taken several measures to improve access to essential neonatal and obstetric care. In terms of policies and strategies, the MoHS has developed several documents to provide relevant technical guidance to improving obstetric and neonatal care, including the most recently launched RNMCAH&N strategy, Life course Approach Framework to health care, Child survival Action Plan, Guidelines for the Integration of the Integration of Elimination of Mother-to-child Transmission of HIV and Pediatric HIV into RMNCAH&N and TB programs, as well as Essential Package of Health Services, which is currently under review. Reduce households’ out-of-pocket expenditures for obstetric and neonatal care to improve access: • The FHC Initiative abolished user fees for essential obstetric and neonatal health services in all public health facilities. • The country is preparing for the establishment of a Social Health Insurance Scheme to mobilize domestic resources and provide financial protection for the most vulnerable populations. Human Resources for obstetric and neonatal care: • Sierra Leone has increased the local production of quality undergraduate doctors, midwives and nurses to provide obstetric and neonatal care, with at least one midwife deployed in each chiefdom. • Postgraduate training in obstetrics, gynecology, and pediatrics is ongoing in Freetown to provide specialized obstetric and neonatal care. 122 Chapter 5 - Human Capital in Sierra Leone: The Way Forward • The country is also training and deploying surgical Community Health Officers to provide caesarian sections in all emergency obstetric and new-born care facilities. • In-service on-the-job training, mentoring, and coaching are also being provided to improve the quality of care at various health facilities. Improving quality of care for obstetric and neonatal care: • MoHS has established a quality-of-care program that provides capacity building in quality-of-care approaches for health workers across the country. • The MoHS conducts maternal death surveillance reviews for every maternal death to ensure that all are investigated to ascertain the course of death and take corrective measures to prevent reoccurrences. Plans are underway to commence the investigation of perinatal mortalities in the country to ensure that all neonatal deaths are investigated. • Sierra Leone has established a national emergency referral system to direct emergency obstetric and neonatal cases to the district referral hospitals. Health infrastructure and supplies for obstetric and neonatal care: • MoHS has established Basic and Comprehensive Emergency obstetric and New-born Care facilities in all districts in Sierra Leone, except Fabala district, which lacks a Comprehensive Emergency Obstetric and New-born Care facility. • The MoHS is implementing the Saving Lives project, which provides additional support for the provision of specialized obstetric and new-born care. The project supported the establishment of sixteen Special Care Baby units in district hospitals that provide critical care to neonates in fourteen districts in Sierra Leone. • Sierra Leone has added two new essential drugs (Carbetocin and Tranexamic acid) to prevent postpartum haemorrhage, the highest cause of maternal death in Sierra Leone. • MoHS, in collaboration with the National Medical and Supplies Agency and the Directorate of Pharmaceutical Services, plays an advocacy role to ensure that medical supplies are available. The World Bank-Funded Quality of Essential Health Services and Systems Support Project. This project supports the Government’s efforts by investing in selected health facilities in five districts in Sierra Leone to provide quality essential obstetric and neonatal health services through the ‘Hub and Spoke’ model. Investments will focus on quality improvement interventions as well as supplies, human resources, and medical systems to provide essential obstetric and neonatal care to the most vulnerable populations. Sierra Leone Human Capital Review 123 5.2 Priorities and Policy Recommendations in Cross-Cutting Areas More and better spending on human development sectors. There is currently limited Government financing of human capital-related sectors in Sierra Leone, and they are heavily funded by donors. To ensure sustainability and improve human capital outcomes, the Government must increase fiscal space for human development sectors. Social protection programs should expand coverage, including by channeling untargeted subsidies towards targeted transfers. The efficiency and effectiveness of spending on human capital need to be improved. It is also important to reprioritize spending, focusing on proven effective interventions targeting the poor and vulnerable. There is also limited investment in risk-financing mechanisms in Sierra Leone. Disaster response is ad hoc and mostly funded by donors. Several relevant documents exist exploring social protection and disaster risk financing in Sierra Leone, but options have not been implemented. Application of some of these options can provide more fiscal space for shock-responsive social services that can protect human capital during crises. Reducing out-of-pocket expenditures for households to improve access to health and education services. Although the MoHS makes provision to provide free health services to children under the age of five, it has become clear that most of the services are not free. The cost associated with child health at various levels has led to the impoverishment of the most vulnerable households. These barriers can be removed by increased investment in the health systems through an increased provision of medical and nonmedical supplies, equipment, improvement in the available infrastructure, and referral systems. In education, the challenges are similar. Despite introducing the FQSE program, parents still have to pay out of pocket to access basic education services. Increased financing of the education sector would help offset some of these costs, and increased funding for operations and maintenance of schools would also help relieve some of this burden. Tackling other demand-side barriers to health and education services to accompany investments that enhance the quality of care and education. Improving the quality of services through supply-side investments will be necessary, but insufficient to ensure high coverage of essential health and education services. For instance, multiple factors inhibit people’s access to care. To address these factors, it is critical to identify strategies to reach communities and explore which communication channels are more effective. This can also help segment the population and design targeted communication messages. Moreover, changing patterns in access and utilization of health services will require promoting health-seeking behaviors and establishing trust between health providers and communities. Regarding education, demand-side barriers include school- related GBV, teenage pregnancy, and early marriage, in addition to the cost of schooling (which comprises both out-of-pocket and opportunity costs). Human-centered approaches that consider the specific needs and preferences of communities will be needed to remove barriers to access. In addition, while free care and basic education services will reduce out-of-pocket expenditure, vulnerable groups may need additional incentives and support to access and utilize such services. Social protection mechanisms (e.g., vouchers or transport allowances) should target these groups to ease financial barriers for priority health and education services. Strengthening health and education workforce management and creating better environments to recruit and retain the workforce. Sierra Leone lacks a comprehensive health workforce management system, career development, and progression pathways. While these issues are well established in the health ministry, resolving them remains challenging. The situation has resulted in inequitable staff distribution and retention, particularly in rural communities. MoHS and health partners need to develop and implement staff management systems to attract and retain the best caliber health workforce in Sierra Leone. In education, the focus on human resource management would be on ensuring more effective deployment of teachers, using various data, including annual school census data, information on the school environment (availability of teaching housing, district, approval status, electricity, and water availability, and main language of the chiefdom), and teacher data (new teachers, qualifications, years of experience, gender), with priority given to females, to match teachers to schools. Improving governance and strengthening implementation capacity. Key aspects of strengthening implementation capacity include strengthening human resource management, improving data management to inform service delivery, and building strong partnerships. Strengthening human resource management 124 Chapter 5 - Human Capital in Sierra Leone: The Way Forward would involve strengthening recruitment practices, providing staff at various tiers of service delivery with the right training, and ensuring the retention of qualified health and education professionals. An important aspect of this would involve developing and implementing effective performance management systems and incentives to improve motivation and retention rates among staff. Strengthening data systems and promoting evidence-based decision-making. Effective implementation of health and education policies requires reliable and accurate data to inform decision-making. Sierra Leone has invested in developing comprehensive data management systems to track education indicators and support evidence-based decision-making. However, efforts should be made to collect more regular information on sector outcomes and beneficiaries, and service delivery. For example, in education, there has been significant progress made in collecting data related to both enrollment figures and educational infrastructure. It is essential to consistently administer student assessments to provide input for necessary interventions. In the health sector, some progress has been made in the implementation of the Health Management Information System (HMIS), yet more needs to be done to improve its functionality. While the country uses District Health Information System 2 (DHIS2), public facilities rely primarily on paper-based data collection systems, and private sector data are not regularly collected by MoHS. There should be more investment in the HMIS to increase capacity for data collection, management, use and feedback at the central, District Health Management Teams and health facility levels. Improving national and local level coordination and partnership in human capital development by convening regular meetings of key education, health, social protection, agriculture, gender and children’s affairs, and water resources stakeholders at the national and district levels. There is a need to regularly convene key stakeholders, including Government officials, civil society, the private sector, development partner representatives, and the media, to discuss human capital challenges and reforms rather than following a sector-specific approach. This national-level human capital stock-taking exercise can help generate consensus and momentum around key reforms. This forum should be very focused and evidence- based in its approach. It should review progress toward achieving key human development indicators and the implementation of reforms in the sector. Existing platforms can be strengthened, expanded, and operationalized for this. These meetings can also be a forum for discussing projects and activities that are cross-sectoral (e.g., school feeding programs, child immunization, de-worming campaigns, etc.). At the local council meetings, decisions and actions taken should be documented and shared with the central ministries and then reviewed at the national human capital stock-taking forum. An example structure of the human capital coordinating platform is presented in Figure 5.1. Figure 5.1 Proposed Structure of Sierra Leone’s Human Capital Coordinating Platform National Level Forum • Convened by MoF, consists of line ministries, development partners, civil society organizations (CSOs), media and the private sector. • Reviews progress against key indicators at national level, regional and local council level. • Reviews implementation progress of key HC reforms. • Reviews local council level performance and takes administrative action – convenes quarterly. Sierra Leone Human Capital Review 125 District Level • Representation consists of representatives of line ministries working at the local council, district level, and the private sector representatives. • Reviews progress against key indicators at the district and sub-district level and takes appropriate administrative action where required. • Coordinates inter-sectoral programs at the local council level. • Reports outcomes of meetings/actions taken to national forum on a quarterly basis. Source: Authors. Building resilient and adaptive human development systems. Sierra Leone needs to build stronger, adaptive, and more resilient systems in human development sectors that can better prevent, prepare for, and respond to future shocks and emergencies. Supporting affected citizens during climate, health, and economic shocks is paramount. Adaptive social protection systems with effective targeting can provide effective means to build the resilience of poor and vulnerable households during crises and shocks. Well-targeted social interventions facilitated by robust data and information systems, and adequate financial resources, can enhance the precision of assistance during shocks or crises. This approach ensures that support reaches those who are most in need. Improving food security through strengthening agricultural productivity, enhancing access to nutritious food, and building resilience to climate change. The country can take various steps to improve food security, which is a critical component in ensuring children and adults are able to realize their full potential: • Strengthening Agricultural Productivity: (a) enhance agricultural research and development: increase investments in agricultural research and development to improve crop varieties, develop resilient farming techniques, and promote sustainable agricultural practices. Collaboration with international research institutions and knowledge-sharing platforms should be prioritized (World Bank, 2020a); (b) improve access to quality inputs and services: increase support for smallholder farmers by ensuring reliable access to quality seeds, fertilizers, and mechanized equipment; and (c) strengthen extension services to provide technical assistance and training on modern farming techniques, post-harvest handling, and market linkages (World Bank, 2017). • Enhancing Access to Nutritious Food. (a) Promote nutrition-sensitive agriculture: encourage diversified and climate-resilient agricultural practices, emphasizing the production of nutritious crops such as fruits, vegetables, and legumes. Support small-scale farmers in adopting post- harvest management practices to reduce losses and increase the availability of nutritious food (World Bank, 2016); (b) improve food access by strengthening markets and road networks, and (c) provide cold-chain facilities to reduce post-harvest losses. 126 Chapter 5 - Human Capital in Sierra Leone: The Way Forward • Building Resilience to Climate Change. (a) Invest in climate-smart agriculture: promote climate- smart agricultural practices, including agroforestry, conservation agriculture, and improved water management techniques. Strengthen early warning systems, weather forecasting capabilities, and climate information services to enhance adaptive capacity (World Bank, 2019); and (b) develop risk management mechanisms: establish agricultural insurance schemes and innovative financial instruments to help farmers manage climate-related risks. Support the development of community-based adaptation strategies, such as farmer field schools and watershed management programs (World Bank, 2017). Tackling social-cultural norms through community engagement and sensitization programs. Community involvement, including religious groups, to promote positive behavior should be explored to provide crucial cost-effective health preventive services at the community level. This initiative will promote trust-building in the health system and address other basic barriers to health care, including vaccine uptake, family planning interventions, nutritional services, and early pregnancies. Mother support groups should be encouraged to continue the provision of malnutrition prevention interventions in the communities. These groups have been found very important in preventing malnutrition and child deaths in the local communities. There are also examples from the region that have tried to challenge social norms through advocacy campaigns, such as Nigeria’s Family Planning Communication Campaign, which utilized mass media to disseminate information and promote the benefits of family planning. Sensitization programming about the value of all people is necessary for education, particularly regarding social inclusion. When communities value all of their children and believe that all have equal economic rights, and when societal beliefs about disability are challenged, communities can hold each other accountable to ensure that resources are shared. Awareness programs relating to child protection and those targeting young women to pursue historically non-traditional fields of study would also contribute to tackling social norms that discourage broader female participation in traditionally male-dominated courses and occupations. Other key interventions to help tackle social-cultural norms inhibiting human capital development would be to ensure that the education curriculum is gender sensitive to challenge traditional gender roles and stereotypes, introduce mentoring and career guidance programs to support young women in pursuing male-dominated courses or careers, and further support ongoing scholarship initiatives for women to study in fields like STEM. Leveraging technology to improve health and education service delivery. To take advantage of technology, there is a need to address the existent digital infrastructure gaps. Despite the rapid increase in technology and innovation, the requisite infrastructure to aid its widespread penetration and adoption in the country is still largely inadequate. Prioritization of the provision of basic infrastructure, such as electricity and internet services, enabling citizens to fully reap the benefits of innovation is required. While considerable progress has been made in providing the abovementioned services over the past few years, key structural gaps make their supply expensive and inconsistent. Tackling these existent infrastructure gaps will also have positive spillover effects on other parts of the real economy and foster foreign direct investment by lowering the costs of doing business in Sierra Leone. In education, there is scope for better-utilizing technology to support teaching and learning, while in the health sector, technology can further support health facilities, facilitate the dissemination of knowledge among patients, and enhance overall healthcare delivery (see Box 13). Sierra Leone Human Capital Review 127 Box 13. Ongoing Efforts to Leverage Technology in Sierra Leone An example is the trial AI chatbot ‘teacher.ai’ from Fab Data, which the MBSSE is currently piloting. The WhatsApp-based chatbot provides teachers with real-time knowledge, responding to their queries. Such approaches can even cater to the remotest, untrained or poorly trained teachers and, with a little introductory guidance, can be used to support improved teacher quality and classroom behavior. The MoHS, in collaboration with the DSTI, recently developed a Pregnancy Registration and Service Tracking (Pres Track) app to promote improvement in maternal and child health outcomes. This mobile app allows pregnancies to be registered, tracked, monitored, and linked to health facilities to get the necessary health services. Preliminary Data generated from the testing of the app is promising in improving the maternal and child health situation. DSTI has expanded the testing of the app to 40 health facilities in Western Area Urban and Rural districts, with plans to further expand to other rural districts in the country to ensure that the app is user-friendly and to identify and resolve any problems before it is transferred to the MoHS. This innovation could be extremely important in improving pregnancy-related outcomes, especially for populations in hard-to- reach and remote communities far from health facilities. Ensuring human capital interventions are targeted to vulnerable groups. For all core issues discussed in this report, it is clear that Sierra Leone’s vulnerable groups are particularly disadvantaged regarding human capital outcomes. These include women, people with disabilities, poor households, youth not in education, employment, or training, and rural youth. Human capital interventions should prioritize these groups to ensure they are able to access quality education and health care, and have safety nets to rely on. Sierra Leone has developed policies to ensure greater inclusion, as discussed in this report. The challenge is operationalizing these policies and ensuring adequate financing to expand access to vulnerable groups. To target vulnerable populations, an essential prerequisite is to ensure that there is adequate data to identify such populations. The MTHE seeks to address this by establishing Disability Units within public institutions to serve as a one-stop shop for real-time data. In addition to data, tailored approaches to target different groups are necessary; for example, to enhance the employability of rural, poor youth with low levels of education, increased access to safety nets and public works programs, funding and training for youth on cultivating more productive crops and leveraging technology through agricultural extension services may be more appropriate. For urban poor youth with low levels of education, self-targeted public work programs focusing on waste management, street and drainage cleaning, and environmental upgradation of cities may be more relevant to increase access to income-earning opportunities (World Bank, 2021a). Protecting and empowering women and people with disabilities. To effectively combat sexual exploitation and violence against girls, women, and persons with disabilities, laws and regulations must be strengthened and enforced. Addressing legal inconsistencies between national and customary laws is also necessary to comply with the Child Rights Act (2007) and reduce the risks associated with child marriage and teenage pregnancies. Amendments to the Customary Marriage Act (2007) should align with the Child Rights Act to prevent marriage before the age of 18 and prioritize consent. Moreover, empowerment programs are essential to reduce power asymmetry between genders and address social barriers to inclusion. Providing access to vocational training and employment opportunities for persons with disabilities, promoting gender equality in decision-making and leadership positions, and supporting women’s entrepreneurship can be effective in this regard. For instance, the implementation of gender quotas in political and private institutions, such as Parliament and businesses, has been undertaken to ensure adequate representation of women. This endeavor is likely to address the issue of self-doubt among women, raised during consultations with young women, by providing strong female role models for them to emulate. A greater number of women in leadership roles and the expression of their agency can positively impact young people, inspiring girls to cultivate their academic and intellectual abilities. 128 Chapter 5 - Human Capital in Sierra Leone: The Way Forward Consequently, an increased number of women in positions of authority would serve as an encouragement for women to assert themselves. Efforts should also be made to reduce the education gap between boys and girls and ensure that children with disabilities have equal access to education. Youth-friendly health services should be provided to girls in schools to reduce adolescent pregnancies and encourage higher education attainment levels for girls. 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