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Findings reports on ongoing operational, economic and sector work carried out by the World Bank and its
 member governments in the Africa Region. It is published periodically by the Knowledge, Information &
                           Technology Center on behalf of the Africa Region.




                    The Process of Health Reform in Sierra Leone

Objective

After years of neglect of its health system, Sierra Leone has had, starting in 1993, remarkable
successes in health reform. As there have been few cases of health reform in Africa, a study was
undertaken to examine the the experience, with particular emphasis on the process of reform (
Bruce Siegel, David Peters, Sheku Kamara, Health Reform in Africa : Lessons from Sierra
Leone, World Bank Discussion Paper, forthcoming ; also Staff Appraisal Report No. 13947-SL).

Impact on the ground

   ·   Broadening the arena of stakeholders: Through interviews, surveys, focus groups, mass
       meetings, task forces, workshops and other methods, thousands of Sierra Leoneans have been
       involved in setting the reform agenda. The health reform effort has been remarkably
       transparent. Results: priorities and strategies bear reasonable resemblance to the expressed
       wishes of the public, and new constituencies have been created.
   ·   Managing the donors: By creating their own National Health Action Plan, the Sierra Leoneans
       were able to establish their own agenda with donors, on their own terms. At the 1994 Social
       Sectors Round Table, the donor community agreed to work exclusively within the framework of
       the NHAP. Donor investments and assistance are being redirected, and a common set of
       objectives is improving the planning and monitoring for the sector.
   ·   Moving to a task culture: Consultant studies early in the reform effort identified the dominant
       culture of the Department of Health as a 'power culture.' Confronted with this perception and
       the need for active decentralization, the top management decided to move towards a task
       culture. Precise indicators of inputs, processes, outputs and outcomes are contributing to focus
       on performance and are beginning to change the way staff act and interact in the Department.
   ·   Clear prioritization: The Department of Health used a variety of methods to establish priorities,
       and build consensus around them. Cost-effectiveness was but one criterion. Focus groups and
       structured interviews contributed more to consensus and 'ownership' of the NHAP priorities
       than rigorous quantitative analysis could.
   ·   Acknowledgment of success: The Department won the Heroes Day Award in 1994 in recognition
       of improved performance in the Sierra Leonean civil service. This type of public accolade helps
       to build a positive environment for reform.

Lessons Learned

   ·   Communication builds commitment but it also builds high expectations. The Department of
       Health now faces the formidable challenge of delivering new services, and managing the
       reactions of the many people and groups consulted on the NHAP.
   ·   Consultation must be continuous. Having taken the step of transparency, the Department of
       Health must continuously demonstrate that its actions were genuine, and not a one-time
       manipulation to gain support for the NHAP.
   ·   Managing donors becomes more, not less complicated. Rationalizing donor and GOSL
       accounting, procurement, disbursement, and auditing requirements is still ahead. But, progress
       has been made.
   ·   New interest groups emerge. The DOH faces new challenges in its relations with the various
       health professions.
   ·   Strong and stable leadership is critical. A new Secretary of State for Health took personal charge
       of the reform program, and obtained the personal endorsement of the Head of State at the
       public launch of the Department of Health's National Health Action Plan. Stability of leadership
       over several years was key to success.

Key Documents on Health

World Development Report, World Bank, 1993

Better Health in Africa, World Bank, 1994

Disease & Mortality in Sub-Saharan Africa, Richard Feacham, Oxford University Press, 1991

Disease Control and Prevention, World Bank, Oxford University Press, 1993

Financing Health Services in Developing Countries, World Bank, 1987

A New Agenda for Women's Health & Nutrition, World Bank, 1994

Managing the Quality of Health Care in Developing Countries, Willy De Geyndt, 1995

Cost Recovery in Public Health Services in Sub-Saharan Africa, Vincent Turbat & Brian Nolan,
EDI, World Bank, 1995

Good Health Low Cost, Rockefeller Foundation, 1985

Health Research, Commission on Health & Research for Development, Oxford University Press,
1990
UNICEF Annual State of the World's Children, Annual

UNDP Annual Human Development Report, Annual

Financing Health Care in Sub-Saharan Africa through User Fees and Insurance, R. Paul Shaw
and Charles C. Griffin, World Bank, 1995

Framework and Indicators of Cost Analysis for Better Health in Zimbabwe, Zia, Yousef, World
Bank, 1993

The Broad Sector Approach to Investment Lending: Sector Investment Programs, World Bank
Discussion Papers, Africa Technical Department, Series No. 302.



For more information on this specific study or copies, contact P.C. Mohan, Rm. J5-171,
Knowledge, Information and Technology Center, World Bank, 1818 H Street, N.W.,
Washington, D.C. 20433. Tel (202) 473-4114 or INTERNET at: pmohan@worldbank.org.