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Table 3 Summary of health system barriers and opportunities for NCD prevention and management in Sierra Leone

From: Opportunities and challenges for delivering non-communicable disease management and services in fragile and post-conflict settings: perceptions of policy-makers and health providers in Sierra Leone

Domain of health systems frameworkOpportunitiesChallenges
Developing political commitmentReinforcing leadership and strengthening the capacity of the health system for prevention and control of NCDs was a key objective in the national policy.Efforts have focused on reproductive, maternal and child health, and communicable diseases.
Low attention paid until recently to NCD. Implementation has been limited in the face of competing priorities and limited resources.
Creating explicit processes for priority settingPolicy priorities include regulatory, fiscal and educational reforms.
The priorities reflect international best practice.
Evidence gaps relating to NCDs mean that the basis for priority setting is absent.
Strengthening interagency cooperationAn interim national technical working group was established in 2018.
There are plans to set up a substantive Technical Working Group that encompasses all the relevant actors.
The NCD directorate is in the process of establishing an NCD and injury commission. Facility Management Committees and Village Development Committees can be a potential platform to conduct NCD prevention and control.
The interim group does not have a strong intersectoral presence.
There is weak NCD coordination at district level where external support is lacking.
Enhancing population empowermentThe national NCD policy is built around eight key principles, with health promotion and education a priority.
The importance of outreach and health education to address causal factors is recognised in principle.
No programmes in operation specifically target at health literacy or knowledge of entitlements in relation to NCDs.
Knowledge of communities is limited.
Perceptions of quality of care is compomised due to medicine stock-outs and distance.
Informal providers preferred by some population groups.
No formal peer support groups exist.
Growing risk factors include: adopting western lifestyles; urbanisation; smoking and alcohol drinking; sedentary lifestyles.
Diabetes and hypertension are increasing.
Establishing effective models of service deliverProviders have received some teaching on NCDs during their pre-service training.Lack of policies to support early detection of NCDs.
Access to palliative care is very limited.
No national guidelines or desk guides for NCD management were in operation at primary care level.
Care has been dependent on knowledge of the providers and availability of equipment.
Public facilities have limited opening hours.
Services at primary care level were reported to be limited.
Weak referral systems.
Limited specialist services are available.
Establishing coordination across providerMoHS has a vision for a coordinated approach to NCDs across levels of the health system.
Community health workers (CHWs) have recently been established.
Traditional healers are trusted by many NCD patients.
Informal sector can also play an important role.
Little implementation of MoHS policies.
Patients often present late with complicated symptoms.
Private and informal providers are posing potential barriers for quality, continuity and loss to follow up.
Traditional healers reported to be overstepping their boundaries.
Taking advantage of economies of scale and specialisationLess relevant at this stage given low levels of coverage for NCD services.
Creating the right incentive systemFiscal, regulatory and communication proposals developed.Resourcing is currently very limited and actions have not yet been put in place. Implementation of WHO’s Framework Convention on Tobacco Control (FCTC) for Sierra Leone was estimated at only 9%.
Integrating evidence into planningInternational evidence has been incorporated in MoHS strategies and plans.There is an urgent need for more locally generated evidence. The STEP survey conducted in 2009 was incomplete. The National Steering Committee has not yet been established. Little progress has been made in implementing and therefore evaluating the national NCD policy and strategy.
Addressing human resources challengeWork is on-going to improve the basic and in-service training for NCDs.
Health talks are given by community health nurses in the health centres and during outreach activities.
Human resources for health are generally inadequate in number, distribution and supportive working conditions. Many staff are not yet on payroll. More assessment of competence in managing NCD care by different cadres is required.
In-service training is ad hoc and typically project-linked, with little emphasis on NCDs.
Staff needs skills-building in a number of NCD-related areas, including providing lifestyle counselling.
Improving access to quality medicines for NCDThe Free Health Care Initiative provides free drugs for pregnant and lactating women and under-fives.
The government supplies methyldopa, suitable for high blood pressure in pregnancy to health centres (though this is not reliable).
Some CHOs have worked with DHMTs and local chiefs to try to control the activities of pepper doctors.
Lack of medicines in public facilities.
Lack of national budget line or programme funding for NCD medicines and general problems with the central purchasing of pharmaceuticals.
NCD drugs generally fall within the cost recovery pharmacies at public health facilities.
Many purchase poor quality drugs or have no access.
A private faith-based clinic in Makeni that provides free insulin treatment faces high patient loads.
Basic diagnostic equipment is often lacking or malfunctioning.
Staff are in a potential conflict of interest situation if they buy and sell on medicines to patients.
Informal drug peddlers are illegal but popular among NCD and other patients.
Strengthening health system managementThe NCD and Mental Health Directorate at the MoHS provides overall leadership and NCDs are integrated within routine health system management structures and processes.NCDs receive relatively little prominence within the sector at all levels.
Creating adequate information solutionMonthly reports sent to DHTM and MoHS.Health data on NCDs suffers from lack of completeness, fragmentation, and limited detail or disaggregation.
Overcoming resistance to changeA draft Tobacco Bill is currently ready for review.Relatively limited action has been taken to date. Challenges include low levels of health education, economic resources and trust in formal services.
Ensuring access to care and reducing financial burdensSome support is available through non-governmental projects and small-scale donor support.Physical and financial access to NCD services is challenged, especially in rural areas. There is no policy in place to subsidise care for NCDs. Informal sector can be costly and is of unassessed (likely to be low) quality.