Government of Sierra Leone Ministry of Health and Sanitation

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1 Better Information, Better Planning, Better Health JAN-JUN 2016 Volume 5, Issue 1 Health Information Bulletin Introduction 1 Data Quality & Reporting rates 1 Government of Sierra Leone Ministry of Health and Sanitation Maternal Health Services 2 Ante Natal Care 3 Deliveries & Complications 4 Child Health Services 4 Immunisation coverage 4 Penta 1-3 Dropout 5 Growth Monitoring 5 Vitamin A 6 Deworming 6 Early Breastfeeding 6 Malaria Management 7 Uptake of ACT 8 HIV/AIDS PMTCT 8 TB and Leprosy 10 TB Treatment Success Rate 11 Lost to Follow-up 11 Role of CHWs Introduction T his edition of the half-yearly MOHS health information bulletin covers the period from January to June 2016 and presents data received from public health facilities across the country. Primarily, it collects data from peripheral health units like Community Health Centres (CHC), Community Health Posts (CHP) and Maternal and Child Health Posts (MCHP). Section One of this bulletin discusses data quality and reporting rates looking at improvements in the data reporting rates by district. Section Two covers maternal health services, focusing on ante natal care (ANC), deliveries and complications. Section Three looks at data on child health services, which includes Immunization, nutrition surveillance, deworming, malaria management; and early infant breastfeeding. Section Four presents data on HIV testing and treatment, while section five presents data on tuberculosis and leprosy, including case notifications and treatment success rates. The final section looks at data on community health workers (CHWs) and their contribution to maternal & child health services. 1.1 Data Quality and Reporting Rates O ver the past year, the Directorate of Policy, Planning and Information in collaboration with the DHMTs, Programmes and Directorates of the MOHS, with support from its development partners, has made notable progress in improving the country s health management information systems. This has resulted in remarkable improvements in reporting rates and quality of routine health data reported by the DHMTs. Over the past six months, the directorate has organised several data quality trainings for District M&E officers, programme M&E officers and data entry clerks. In addition, the Directorate has carried out

2 quarterly supportive supervisory visits to the districts with the objective of conducting data quality audits at the district level and at health facilities to identify and address persisting data quality issues. The supervisory visits also provided an opportunity to coach and mentor staff at the DHMTs and health facilities on data quality improvement. The Directorate of Policy, Planning and Information has conducted a series of M&E and DHIS2 trainings for M&E/HMIS staff at the MoHS and DHMTs. Over the past year, DPPI has worked tirelessly to ensure that DHIS2 is accessible to all relevant users of national health data, ranging from individuals to institutions. All district and programme M & E Officers as well as health partners including Non- Governmental Organisations and United Nations partners have been trained in the use of DHIS2, in a bid to increase access to health data and promote the use of health information for programme improvement and decision making. would need additional support from the national office to help improve the district s reporting rate. It is imperative that the DPPI team continue engaging the lower scoring districts in general, to provide the support needed to improve reporting. Figure 1 below presents reporting rates by district (Jan-Jun 2016). The Directorate has also been working in close collaboration with individual programmes to integrate their data into the DHIS2 and establish a harmonised health information system. So far, programmes like Malaria, TB and HIV have been fully integrated into the DHIS2. This ensures that data reported by programmes is reflective of data entered into DHIS2. Programme M & E officers are empowered to check their respective programme data in the DHIS and edit where necessary. National reporting rates increased from 81% for July through December 2015, to 89% for the period under review. There appears to be a constant trend among the districts in terms of improvements in data reporting compared to the previous half yearly report; Kenema District maintained the highest reporting rate at 99%, while Western Area urban still had the poorest reporting rate at 78%. Both districts however, recorded improvements from their previous reporting rates of 95% and 71% respectively. Pujehun District recorded the second best reporting rate of 96%, while Kailahun had the second worst reporting rate at 80%. Kailahun has also maintained a relatively low ranking in the last eighteen months and Source: DHIS2 2.0 Maternal Health Services A s Sierra Leone still records one of the highest maternal and child mortality rates in the world, the Government of Sierra Leone has designated Maternal Health Services priority status in an effort to address the high maternal mortality rates. A number of initiatives have been introduced to improve service provision. One of these is the Free Health Care Initiative introduced in In addition to the FHCI, the Reproductive and Child Health Directorate (RCH), in collaboration with development partners, introduced the Maternal Deaths Surveillance Response system. With the introduction of this initiative, focal MDSR persons are now able to promptly report maternal deaths and its causes at community level. From data collected through MDSR real-time reporting, the Reproductive Health Programme reports that 354 maternal deaths occurred for the period covering January to June 2016 a much lower figure than was

3 expected based on the WHO projection of 1,550 maternal deaths for This ministry is committed to continuously improving data quality and timeliness of reporting, in order to maintain improved maternal outcomes and increase public confidence in maternal health initiatives. For the period under review (Jan-Jun 2016), a total of 144,103 pregnant mothers were reported to have attended ante-natal clinic for the first time; out of this number, only 107, 512 women completed all four ANC visits (ANC4). See Figure 2 for ANC 1 & 4 attendance for Jan-Jun Figure 2: ANC1 and ANC 4 Attendance (Jan-June 2016) To further improve maternal mortality statistics, the Government of Sierra Leone has introduced the National Emergency Medical Services (NEMS) as a way to respond to health emergencies, especially those affecting maternal health. NEMS plans to preposition ambulances in all 149 chiefdoms across the country to help address emergencies, including complicated delivery referrals. With support from its development partners, Government also acquired a sea ambulance to transport emergency cases from Bonthe Island to the mainland where better medical services are available. All these services are geared towards improving quality and quantity of healthcare services provided to the populace, especially women and children. This section presents three key indicators that track the status of Maternal Health Services: Ante Natal Care, Deliveries and Complications, and Distribution of Insecticide Treated Nets to prevent malaria in pregnancy. 2.1 Ante Natal Care (ANC) Attendance P regnant mothers attend ante-natal clinic to access essential health services including advice on prevention and treatment of sexually transmitted infections (STI) such as HIV/AIDS, and prevention and treatment of malaria, tetanus immunization and family planning. Sierra Leone s Ministry of Health and Sanitation recommends a minimum of four ANC visits, by every pregnant mother, so that possible pregnancy or delivery related complications can be detected early and appropriate measures taken to prevent or minimise any adverse effects on the mother or child. District ANC 1 Attendance ANC 4 Attendance Bo Bombali Bonthe Kailahun Kambia Kenema Koinadugu Kono Moyamba Port Loko Pujehun Tonkolili W/Rural W/Urban National Source: DHIS2 T his indicates a 25% dropout rate on ANC attendance. This is an increase in ANC4 dropout rates as compared to the previous six month period, when the dropout rate was reported to be 20%. Koinadugu had the highest dropout rate (41%) for the period covering January- June 2016, followed by Western Urban district with 38% dropout rate. The lowest dropout rate was reported in Kailahun district at 7%, followed by Bo district at 10%. Source: DHIS2 3

4 2.2 Deliveries and Complications M aternal deaths are often caused by delivery complications. Delivery outcomes can be significantly improved when delivery complications are properly managed. 110,451 deliveries in health facilities were reported in the period under review. 13,585 deliveries were reported to have taken place at hospitals, with the rest taken at PHUs. Western Area (combined) reported the most deliveries in health facilities within this period, with 17,978 facility deliveries; followed by Kenema with 11,750. Bonthe reported the lowest number of facility deliveries, with only 2,811 deliveries reported for the period under review. Nationally, there were a total of 4,710 delivery complications referred, with Western Area recording the highest complications referred (667), followed by Bonthe and Kambia reporting 91 deliveries referred for complications in each district. To improve referral systems, government has procured over 200 ambulances. Figure 4 below presents numbers of facility and complicated deliveries referred from January to June Figure 4: Number of Facility Deliveries and Delivery Complications (Jan-Jun District PHU 2016) Facility- Deliveries Hospital Deliveries Deliveries Complications referred Bo Bombali Bonthe Kailahun Kambia Kenema Koinadugu Kono Moyamba Port Loko Pujehun Tonkolili W/Area NATIONAL 96,866 13, ,451 4, Child Health Services C hild health services cover a wide range of services targeted at improving the overall health of the child. This section looks at some key indicators of including immunisation coverage, nutrition and malaria management. 3.1 Immunisation Coverage A child is considered fully immunised when they have received complete and timely doses of BCG, OPV0, Penta 1, OPV1, Rota 1, Penta 2, OPV2, Rota 2, Penta 3, OPV3, Measles and Yellow Fever. EPI programme data for the half year under review shows that 87% of children in the country were fully immunised. Western rural and Moyamba districts recorded the highest in excess of 100%. Bo reported the lowest percentage of fully immunised children (FIC) at 60%, followed by Port Loko reporting 65% FIC. These figures reflect a slight drop in the national FIC rate, when compared to the previous half year, with a reported national rate of 89%. It is however, difficult to determine whether this is indeed an improvement or not, because there are at least three districts with an excess of a 100% but there is Penta 1- Penta 3 dropout rate recorded for those same districts. Penta 3 is a required vaccine for the fully immunised child indicator. There are certainly data quality issues here that require further investigation with the EPI programme to determine what the issues are and agree on measures to improve data accuracy. It must be noted that this data discrepancy in the FIC data is not surfacing for the first time. See Figure 5 below for details of fully immunised children for the Jan-Jun 2016 period. 4

5 3.2 Penta 1-Penta 3 Dropout Rate I n accordance with WHO and MOHS recommendations the National EPI programme works to ensure that all children receive a minimum of three initial Penta vaccines. Programme data shows a 6% dropout rate nationally, which is at variance with the national FIC rate of 87%. Western Rural recorded the lowest dropout rate at 1%, followed by Kenema with 1% dropout rate. The highest dropout rate was recorded by Koinadugu and Tonkolili with 13% each. This incongruence with the FIC data for the respective districts needs to be further investigated by the programme. Please see Figure 6 below for Penta 1-Penta 3 dropout rate (Jan-Jun 2016). 3.3 Nutrition: Growth Monitoring M alnutrition continues to remain a crucial health issue affecting child survival and development in Sierra Leone. Consequently, the Government of Sierra Leone has made this a priority by including Child Nutrition Services into the presidential recovery priorities, which are directly supervised from Office of the President. Programme data on malnutrition tracks both moderate and severe acute malnutrition. Data for the period under review indicates that there is a decline in children s nutritional status across the country. Severe acute malnutrition, is reported at 4.0% compared to the 3.5% reported in the previous half year. The programme recorded minimal improvements in moderate malnutrition (MAM) rates, reporting 13.4% during the period under review compared to the 13.8% in the previous half yearly report. Port Loko reported the highest severe acute malnutrition (SAM) rate of 6.5%, while Kailahun reported the lowest SAM rate of 0.5%. Similarly, Port Loko recorded the highest MAM rate of 24.5% while Kailahun reported 2.5%. See Figure 7 for severe and moderate 5

6 3.4 Vitamin A Supplementation (VAS) V itamin A deficiency can lead to increased susceptibility to illnesses such as acute diarrhoea, acute respiratory infections, skin infections and preventable blindness. VAS primarily aims to strengthen a child s immunity to increase their resistance against these common diseases. For the period, the national coverage for routine VAS for the 6-11 months age group was reported at 15%, a marked decline from 32% supplementation coverage reported in the previous reporting period. National VAS coverage for months declined from 16% to 7% for this reporting period. The Nutrition programme would need to look into the causes of this decline and address them. It is worth noting that although there is a general decline in VAS coverage, Kailahun and Kono reported the highest rates at 20% for 6-11 month age group, while Bonthe recorded the lowest at 9% for the same age group. For the month group, Western Urban and Koinadugu districts recorded the highest coverage of 11% each while Western Rural recorded the lowest at 1% followed by Bonthe district at 4%. Figure 8 below presents data on VAS coverage by district for the period Jan-Jun Deworming (12-59 Months) W orm infestations are among the most common infections in young children under the age of five and contribute significantly to infant morbidity and mortality. Periodic deworming is recommended to prevent infestation, which could otherwise lead to nutritional and cognitive impairment, tissue damage and internal bleeding. Compared to the previous half year, there has been a sharp decline in reported deworming rates, with a national rate of 5.6% reported for this period, against 22% reported for the previous half year. Port Loko reported the highest deworming rate at 9.2% followed by Koinadugu district which recorded 8.9%. The lowest rates were reported from Tonkolili at 0.9% followed by Western Rural with 1% of children dewormed for the reporting period. Figure 9 below indicates % coverage of deworming for the period January to June 2016 by district. 3.6 Early Initiation of Breastfeeding N ational Infant feeding recommendations are aligned with WHO recommendations of exclusive infant breastfeeding for the first six months of life. In keeping with this, the Nutrition Programme tracks early initiation of breastfeeding as a proxy indicator for exclusive breastfeeding. This indicator captures children who are given breastmilk within the first twenty-four hours of birth. 6

7 For the period under review, the Nutrition Directorate s programme data indicates a three percent national increase (98%) in early initiation of breastfeeding compared to the previous half year (95%). Kenema, as in the previous half year, recorded the highest (104%). Kambia also recorded 104% followed by Pujehun (103%). Bombali recorded the least (90%) closely followed by Bonthe 92%. It is worthy to note here that four districts, including Kambia, Kenema, Pujehun and Western Rural recorded percentages in excess of one hundred. This could be attributed to lower projected rates of population growth used as the denominator for this indicator. Figure 10 shows % early initiation of breastfeeding for January to June 2016 per district The National Malaria Programme has adopted established strategies for the prevention and control of malaria to reduce morbidity and mortality, particularly among pregnant women and children under the age of five years. These strategies include the distribution of insecticide treated nets (ITN) to pregnant women and their households, administration of Intermittent Preventive Treatment (IPT) and appropriate case management through prompt diagnosis and effective treatment with Artemisininbased Combination Therapy (ACT). The malaria programme tracks two key indicators: the distribution of bed nets and ACT uptake across all districts. Programme data for the period under review shows that 264,265 bednets were distributed to pregnant women and children under the age of five years, with 100,572 bed nets distributed among children under-five and 163,693 ITNs distributed to pregnant women during their ANC visits throughout the country. Tonkolili distributed the highest number of bed nets (41,457) with under-fives and pregnant women receiving 22,833 and 18,624 respectively. Bonthe distributed the least with 8,193 ITNs. Figure 11 below shows number of ITNs distributed to under-fives and pregnant women per district for the period January to June Figure 11: ITN Routine Distribution (Jan-Jun 2016) 3.7 Malaria Management M alaria still remains the biggest killer disease in Sierra Leone, predominantly affecting pregnant women, and children below the age of five years. Under Fives Pregnant Women Total Bo 7,078 14,145 21,223 Bombali 5,620 9,640 15,260 Bonthe 2,968 5,225 8,193 Kailahun 4,182 7,767 11,949 Kambia 3,616 7,120 10,736 Kenema 11,893 21,634 33,527 Koinadugu 4,647 12,948 17,595 Kono 4,810 8,843 13,653 Moyamba 6,525 11,433 17,958 Port Loko 11,001 19,175 30,176 Pujehun 5,874 9,366 15,240 Tonkolili 22,833 18,624 41,457 Western Area 9,525 17,773 27,298 National 100, , ,265 Source: DHIS2 7

8 3.8 Uptake of Artemisinin-based Combination Therapy (ACT) T he table below shows the number of people reported to have been treated with ACT for malaria during the period under review. Figure 12: People Treated with ACT (Jan-Jun 2016) Under Fives Adolescent Adults Total Bo Bombali Bonthe Kailahun Kambia Kenema Koinadugu Kono Moyamba Port Loko Pujehun Tonkolili W/Area Total Source: Programme Data 4.0 Prevention of Mother To Child Transmission (PMTCT) HIV/AIDS H IV remains a major global public health concern, especially for developing countries. Although prevalence rate of the disease has remained low Sierra Leone for the past few years, it is still a serious public health concern. One of the key areas of focus for the national HIV AIDS programme is the prevention of mother to child transmission (PMTCT) A key component of the prevention of mother to child transmission approach is the provision of HIV counselling and testing for pregnant women. In the period under review 98,705 pregnant women were tested for HIV. This corresponds to 63.5% of the national programme target; Of those tested 1,321 were newly tested positive. HIV 1 was the predominant serotype accounting for 95.3% of HIV infections. A total of 1,580 received antiretroviral treatment; this comprises 1,214 new and 471 patients already on ART. A national achievement of 106.6% was realized compared to 67% of the same period in Details are found in the table (Figure 13) below Figure 13: National Achievements against Targets (Jan-Jun 2016) Data elements Jan - Apr- Jan - Jun Target Mar, Jun, # Women tested for HIV 47,722 50,983 98,705 # Women HIV positive HIV ,259 # Women HIV positive HIV 2 # Women HIV positive HIV 1 & 2 # Women received post-test counselling Source: Programme Data National Achievement 47,722 50,983 98, , % # HIV positive women already on ART who initiated follow-up for their pregnancy this month # of HIV-infected pregnant women initiated on antiretroviral to reduce the risk of mother-to child transmission ,214 1, % 8

9 S uccess in reaching the level of achievement in PMTCT was as a result of the introduction of new strategies and policies in the option B+ For HCT and PMTCT, challenges were associated with shortage of test kits and other consumables as well as inadequate logistical support to the district and regional supervisors to undertake mentoring and supportive supervision at the facilities. Figure 15: People on ART (Jan-Jun, 2016) Data element Number of old patients who were supplied with ARVs Number of new patients started ARVs Number of patients transferred in Number of defaulters (adults) Number of children < 15 years currently receiving ART Total number of clients (adults & children) currently receiving ART Source: Programme Data Male 3,08 7 Female 9,420 Total 12, ,147 1, , , ,39 0 Within the period under review, 15,390 people (adult and children) were receiving treatment. Figure 15 below provides a detailed account of people receiving antiretroviral treatment (ART) B etween districts, Western urban recorded the highest number of patients (6032) on antiretroviral treatment, females accounting for Moyamba recorded the least with 211 on treatment. Figure 16 shows number (adults and Figure 16: Number of Adults and Children currently on Treatment (Jan-Jun 2016) District Male Female Total Bo Bombali Bonthe Kailahun Kambia Kenema Koinadugu Kono Moyamba Port Loko Pujehun Tonkolili Western Rural Western Urban National Source: Programme Data 9

10 5.0 Leprosy and Tuberculosis Control Programme and Case Notifications T he vision of the National Leprosy and Tuberculosis Control programme is effective diagnosis and treatment until the diseases cease to be public health problems. The programme s main strategy in the management and control of TB infection is Direct Observed Treatments (DOTs) which is used at all levels of care at the community, in 170 service delivery points in the country. nationwide and breaking the chain of transmission if the vision to End TB in Sierra Leone is to be achieved. Between January and June 2016, a total of 4,090 notifications for TB and 78 for leprosy cases were done. While Western Urban recorded the highest case notifications for TB (1021), Koinadugu recorded the highest for Leprosy (16). I n 2015, there were a total of 12,103 TB case notifications with all cases treated. For the period of Jan June 2016, 6,891 patients were put on TB treatment, which is 85% of the target. During the same period, there were 78 Leprosy cases identified and put on treatment. 60% of the TB cases were sputum positive, thus the need for cough hygiene Figure 17 on next page shows number of TB and leprosy case notifications between January and June 2016.

11 Figure 17: No. of Leprosy and Tuberculosis Cases notified (Jan-Jun 2016) District No. of new SS +VE TB cases Notified No. of Leprosy Cases Notified Bo Bombali Bonthe 47 4 Kailahun Kambia Kenema Koinadugu Kono Moyamba Port Loko Pujehun 96 1 Tonkolili W/Rural W/Urban National Source: Programme Data 5.1 Treatment Success Rate T uberculosis is treatable and curable if it is promptly diagnosed and properly managed and treated according to national TB treatment guidelines. Eleven districts out of 13 achieved treatment success rates above 90%, with Koinadugu and Bonthe both recording 100% success rates. Bombali and Western Urban reported TB treatment success rates of 84% and 85% respectively for the period under review. This is an improvement from 2015 achievements. Western Rural, however, reported a significantly low treatment success rate of 59%. This is a matter of concern and it is imperative that the TB programme promptly looks into the reasons for this low treatment success rate reported in Western Rural and urgently undertakes measures to address any identified problems. See Figure 18 for treatment success rate. 5.2 Lost to Follow Up (Defaulting) Loss-to-follow-up (LTFU) is one of the key factors driving the emergence of multi-drug resistant strains of tuberculosis. The national LTFU rate of 3.7% is within accepted WHO limits and shows an improvement from the 2015 Jan June figures of 6.9%. Unacceptably high LTFU rates were recorded in 2 districts Bombali (6.7%) and Western Area (Rural 6.3% and Urban 5.9%). This high lost to follow up rate in the two districts should be of concern to the programme and measures should be taken to identify the reasons for this unacceptably high LTFU rates. Bonthe, Pujehun, Kailahun and Koinadugu all recorded no defaulters for the period under review. Operational research could be conducted to identify causes and share lessons learnt and best practices from those districts that do not record any defaulters. See Figure 19 for Lost to Follow Up rate for Jan- Jun

12 5.3 Community Health Workers (CHWs) Community Health Workers contribution to maternal and child health services are immense as they provide door-to-door counselling services to women in their catchment communities. In many cases, the CHWs are the first health care workers to meet the women and refer them to the appropriate health facility. During pregnancy, CHWs make home visits to remind pregnant mothers to attend ante natal clinic and also pay home visits to the mothers after delivery to advise or remind them of post natal care. For the period under review, through the community case management programme, CHWs treated 136,676 malaria cases (2-59 months) and 24, 083 pneumonia cases (2-59 months). CHWs also conducted home visits to 44,931 mothers to provide post natal care within the first 48 hours of birth. Please help us improve future editions by sending your comments and suggestions to: 1. Edward Foday DPPI, MOHS Youyi Building, Fifth Floor, East Wing Wogba Kamara DPPI, MOHS Youyi Building, Fifth Floor, East Wing A total of 37,673 children were referred to health facilities by CHWs. CHWs saw 253, 653 cases for various ailments in twelve districts excluding Kono District and Western Area. The production of this bulletin has been supported by GoSL partners, including the World Bank, USAID, the EU, and UK Aid (DFID), among others 12