Monitoring and Review of Health Investments
Location: Sierra Leone
Montrose has been contracted by the Department for International Development (DFID) to provide the Monitoring, Evidence, Learning and Review (MELR) component of the DFID Saving Lives in Sierra Leone (SLiSL) programme (running from April 2016 to March 2021). SLiSL aims to save women and children’s lives by improving the quality, availability and accessibility of reproductive, maternal, newborn and child health (RMNCH) services across Sierra Leone. The overall objective of MELR is to provide DFID, implementing partners and the Ministry of Health and Sanitation (MoHS) with comprehensive, accurate and informative reports on progress and delivery of the Saving Lives in Sierra Leone Programme.
Despite its small population and rich natural resources, Sierra Leone has a turbulent recent history marked by brutal internal conflict, the Ebola Crisis of 2014-2015 and the sharp decline of world iron ore prices, in 2014, its major mineral export. Following a period of relative recovery in the years following the end of a major civil war, much progress has been reversed by the devastating impact of the Ebola crisis on service delivery in the health and education sectors. The weak current state of the Sierra Leone health system results in some of the worst health indicators in the world, particularly in relation to infant and maternal health:
- Sierra Leone consistently ranks at or near the top of global infant and maternal mortality rates - In 2013, the country had the world’s highest estimated maternal mortality ratio at 1,165 deaths per 1,000 births and the mortality rate of children under 5 stood at 156 deaths per 1,000 births. One in three deaths among women aged between 15 – 49 years occur during pregnancy and childbirth.
- Fertility rates are high, with 35% of women giving birth before the age of 18 and only 16% of married women using modern contraception.
- Only half of mothers deliver in health facilities and rates of post-natal care are low, with significant disparity between rural and urban areas.
The weak state of the health sector is not only a result of systemic gaps within health care governance and accountability, but also the geography of poverty within the country. Infrastructure remains poor in rural areas which has a knock-on effect on access to health care - 60% percent of Sierra Leone’s population live in settlements of less than 2,000 inhabitants, with only five percent of the total population having access to power, and the majority living more than 2km from year-round accessible roads. This settlement pattern makes it difficult for rural people to access healthcare services and leaves populations acutely vulnerable to preventable diseases such as cholera, dysentery, malaria and tuberculosis. Treatable child birth complications, notably post-partum hemorrhage, hypertension and sepsis, are common killers of rural women.
In light of this context, DFID is funding a wide-ranging four-year programme aligned with the Government of Sierra Leone’s post Ebola Presidential Recovery Priorities for health, to support cost-effective interventions which will improve health service delivery and save maternal and child lives.
Some of these interventions include:
- Ensuring referral facilities across Sierra Leone are able to provide emergency obstetric and neonatal care (EmONC)
- Installing and/or upgrading water and sanitation (WASH) in health facilities
- Rolling out a national community health worker (CHW) programme, providing the critical link between health care needs and service delivery at the community level
- Improving the quality of primary maternal and child health services including supplies, training and supervision;
- Supporting changes in health behaviors on family planning (especially targeting adolescent girls), nutrition and hygiene; and
- Ensuring good data is available for accountability and decision making.
DFID has engaged Montrose as an independent Monitoring, Evidence, Learning and Review (MELR) partner to provide them (along with service providers and the MoHS) with comprehensive, accurate and informative reporting on progress and delivery of the programme.
Montrose will support delivery of the SLISL programme with technical advice and research in the areas of results verification, data quality, value for money, disability, gender and inclusion, and the political economy. As part of our work on programme reporting, we will support the MoHS Department of Planning, Policy and Information (DPPI) to strengthen their capacity to monitor and analyse reports from a range of health sector projects such as SLISL. Montrose will monitor and provide accountability for the delivery of implementing partners’ activities under the programme. These reports will create an evidence-base for decision-making to inform the direction of the programme and will enable Montrose and partners to document lessons learnt.
The MELR component will provide accountability, inform programme decisions and document evidence and lessons learnt. As MELR provider, Montrose will provide the following services to the SLISL programme:
- Support and ongoing refinement of the design of the overall programme monitoring framework
- Compilation, analysis and presentation of results data and other third-party information, supported by review and verification of the data collection processes and quality of service providers
- Capacity building of MoHS staff at both national and decentralised levels to enhance their ability to monitor and report on health data, particularly regarding progress against the President’s Recovery Plan and the Health Sector Strategic Plans.
- Political Economy Analysis of the health sector on an annual basis
- Development of a Value for Money (VfM) framework and annual VfM analysis of the entirety of the programme as well as specific components e.g. procurement
- Qualitative fieldwork to enhance understanding stakeholder and beneficiary perspectives, validate implementing partners’ programme reporting, and to enhance understanding of programme activities
- Operational research studies on specific cross-cutting issues such as disability, gender and quality of care
- Lesson learning and knowledge management support, including development and implementation of a plan for dissemination, with feedback loops to government to improve decentralised delivery
- Production of annual reviews and final project completion review.