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Sierra Leone

Last Updated: December 28, 2011

Senior Program Officer:

Clifford Kamara, MD, MPH

Program Activities:

  • October 2008: Drs. McQuestion and Kamara meet with MOH officials (including the EPI manager) as well as representatives of the World Bank, UNICEF and WHO in Freetown.
  • January 2009: Dr. Kamara meets with Chairlady, Parliamentary Committee on Health, Mrs. Bintu Meyers, as well as with Emmanuel Pewa, Deputy Secretary, and Samuel Aruna, Senior Economist in the Ministry of Finance.
  • March 2009: Dr. Kamara addresses the Rotary Club of Greater Freetown.
  • April 2009: Dr. Kamara assists national EPI team, WHO counterparts, in preparing GAVI pneumococcal vaccine grant request.
  • August 2009: First SVI-sponsored parliamentary briefing held in Freetown.
  • October 2009: Second SVI-sponsored parliamentary briefing held in Freetown.
  • November 2009: Dr. Kamara co-hosts a one-day symposium in Freetown to brief parliamentarians, Paramount Chiefs, Ministry of Health and Ministry of Finance contacts, and representatives from the World Health Organization, UNICEF, and Rotary International, on immunization financing challenges and solutions.
  • December 2009: Sabin sponsored peer exchanger EPI Manager of Liberia meets with key stakeholders and studies SIF issues in Sierra Leone.
  • March 2010: The Chairlady of the parliamentary Health Committee, Honorable Mrs. Bintu Myers, and the Senior Assistant Secretary in the Ministry of Finance and Economic Development, Peter Sam-Kpakra, visit their counterparts in Monrovia as Sabin peer exchangers and participate in Liberia’s first SIF congressional briefing.
  • May 2010: Senior Program Officer Cliff Kamara and Program Director Mike McQuestion confer with Ministry of Health, Ministry of Finance and Parliament counterparts about organizing district-level advocacy efforts.
  • August 2010: Mr. Peter Sam-Kpakra, Ministry of Finance, and his Liberian counterpart Mr. Bernard Jappah visit Uganda as Sabin peer exchangers to study Uganda's performance-based budgeting process.
  • December 2010: Mr. Peter Sam-Kpakra travels as a Sabin peer exchanger and presents Sierra Leone's proposed performance-based budgeting system to colleagues at the 2nd African Regional Immunization Conference in Ouagadougou, Burkina Faso.
  • March 2011: Five Sierra Leonean delegates attend the Addis Ababa Colloquium on SIF.
  • July 2011: Senior Program Officer Clifford Kamara briefs District Council Health Committee members on SIF issues.
  • October 2011: Senior Program Officer Cliff Kamara and Program Director Mike McQuestion confer with Ministry of Finance, parliamentary and Ministry of Health counterparts, including Western Region Health Team and Regional Council members.
  • November 2011: Two Sabin-sponsored subnational briefings are held, one in Makeni for the districts of the North Province: Bombali, Kambia, Koinadugu, Port Loko, and Tonkolili, Kono district in the Eastern Province, and the Western Area and another in Bo, for the districts of the Southern Province (Bo, Bonthe, Moyamba, Pujehun), and Kailahun and Kenema in the Eastern Province.

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    Health Sector Architecture:

    • Sierra Leone is not a SWAp country. However, its health plans are strongly sector-oriented.
    • Sierra Leone joined the IHP+ in May, 2010, when the agreement was signed during the World Health Assembly in Geneva. In collaboration with all major stakeholders, the Health Development Compact is now being prepared and will be signed with in-country partners.
    • Sierra Leone has decentralized its Primary Health Care (PHC) system: PHC administration is now the responsibility of the country's nineteen local councils.
    • EPI is one of six priority programs in the Disease Prevention and Control Directorate of the Ministry of Health and Sanitation. It is integrated into the national Reproductive and Child Health Programme.

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    Health Financing:

    • In 2007, Sierra Leone spent US$32 per capita on health. Health accounted for 8% of recurrent government expenditures. (Source: Countdown to 2015 Report, 2010)
    • In 2008, Sierra Leone received US$26.7m in Official Development Assistance for health, up from US$19m in 2007. (Source: OECD Creditor Reporting System)
    • Three main donors-- UK Department for International Development, the European Community, African Development Bank-- provide about one-third on the government’s overall development budget through direct on-budget support.
    • Highly Indebted Poor Countries (HIPC) / Multilateral Debt Relief (MDR) Initiatives: Sierra Leone began receiving HIPC debt relief credits in 2002. As of mid-2009, the country had received credits totaling US$673m (of a total commitment of $1.67b). As per the Poverty Reduction Strategy Paper (PRSP), the government has used these savings to invest more in poverty-reducing programs, including PHC delivery (from $57.4m in 2002 to $63.3 in 2006). Its pro-poor expenditures have nearly doubled in comparison to pre-HIPC levels. However, revenue and external budgetary support shortfalls caused a decrease in 2006-07. Further increases in pro-poor spending are needed if MDGs are to be achieved. (Source: HIPC and MDRI-- Status of Implementation: September 15, 2009.)
    • Expanded Programme on Immunization (EPI)
      • Since 2005, federal transfers amounting to about a quarter of Sierra Leone’s national health budget have been remitted to the 19 local councils. Some of these funds support immunization services.
      • According to the World Health Organization, the Government of Sierra Leone spent US$2.5m on its routine EPI program in 2001, representing 51 percent of all routine EPI expenditures. For 2002 and 2003 the figures were $2.5m (49 percent) and $2.8m (49 percent). The country received its first GAVI vaccine grant in 2002. In 2006, the government spent $30, 645 on its routine immunization program. The figures for 2007-2008 were, respectively, $0 and $0.9m (10 percent).
      • According to the 2007-2011 cMYP, $3.5m were spent in 2005 specifically on the routine EPI program ($17 per infant born that year). Adding in shared health services expenditures to support EPI increases this to $9.8m ($46 per infant). The government financed $1.8m of the specific routine EPI expenditures (18 percent), about $8 per infant .
      • The overall pattern suggests an increasing substitution effect from 2005: As external partner inputs rose, government investments declined. It was to have increased by 15% per annum over the 2007-2011 period according to the Comprehensive Multi-Year Plan (cMYP).(Source: cMYP, 2007-2011)
      • Efforts are underway to garner additional government funding for EPI within the Minimum Package of Services for Health. Fiscal sustainability must therefore be achieved through a basket funding approach. Sustainability will entail optimizing the mix of long-term external aid with increased domestic revenues.
      • Amount spent (USD) by the government of Sierra Leone on routine immunization per infant (2000-2010)Sierra Leone routine imm spending 2000 2010.jpg

      • Source:
        1. WHO Vaccine Preventable Disease Monitoring System, 2008. Immunization Profile: Sierra Leone. All data derived from the WHO/UNICEF Joint Reporting Form as follows:
        a: C_6450. This % excludes any external financing from donors.
        b: C_6490. This % includes all recurrent, immunization-specific spending financed solely with government funds. This includes vaccines, injection supplies, salaries, and per diems of health staff working full-time on immunization, transport, vehicles, and cold chain maintenance, training, social mobilization, and monitoring and surveillance.
        "NA" indicates data not available.

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    Budgeting:

    • Sierra Leone’s budget process reflects the government’s commitment to decentralization of public services. The country follows a medium-term (three year) planning cycle. Districts are responsible for implementation of the first year of the three-year plan, which constitutes the annual operational plan.
    • There is a line item for immunization in the health sector budget under the Maternal and Child Health budget line.
    • The country's first cMYP for EPI was prepared in October 2006. The annual EPI budget is set through an Inter-agency Coordinating Committee. EPI strategies are compatible with the country's PRSP.

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    Budget Flows and Reporting:

  • In 2006 an Integrated Financial Management Information System was introduced in the Ministry of Health and Sanitation. The IFMIS tracks recurrent expenditures down to health district level.
  • With decentralization, the Ministry of Finance sends the local councils quarterly (general revenue) budget allotments through the Ministry of Local Government. The councils transfer the health sector funds to the District Health Management Teams, which use them to deliver services, including routine immunization. Councils are also encouraged to find complementary resources from NGOs and from the community.
  • The district health teams report program coverage, disease incidence and other health indicators back to the councils and to the Ministry of Health and Sanitation. They also report quarterly expenditure data to the councils. The local councils in turn report expenditures and activities back to the Ministry of Local Government.

    • Click the image below for a visual representation of budget and reporting flows.


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    Budget Performance:

    • In 2006, Sierra Leone's routine EPI Program immunized 145,875 children with DTP3 and spent US$4,481,587 (around US$31 per DTP3 child). (Source: GAVI Annual Progress Report 2006)
    • Country Policy and Institutional Assessment:
      The World Bank 2007 CPIA gave Sierra Leone's budget and financial management systems (Indicator #13) a score of 3.5, equal to its 2005 score. (mean 2007 score for all IDA countries: 3.2) Read more here.
    • Sierra Leone introduced a Medium Term Expenditure Framework in 2001. Since 2001, Sierra Leone has conducted five Public Expenditure Tracking Surveys. The surveys showed that government program performance is limited by a chronic shortage of skilled staff, particularly at district level. The surveys also found disparities between what was budgeted and what was actually distributed. Parliament approved the 2007-09 budget (Appropriation Act) in December 2006. The 2008-10 and 2009-11 budgets were approved after those fiscal years began. (source: Sierra Leone Web)
    • In-year budget execution reports have been produced since 2007 (source: PEFA Assessment 2007).

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      Parliamentary Notes:

    • The Sierra Leone Parliament is unicameral. Twelve seats are reserved for paramount chiefs and 112 seats were popularly elected. All are for five year terms. The paramount chiefs are selected indigenously while the other MPs are individually elected.
    • The current Parliament was elected in 2007. Three main parties are represented: The ruling All People’s Congress (59 seats), the main opposition Sierra Leone People’s Party (43 seats) and the People’s Movement for Democratic Change (10 seats). Eighty percent of the MPs are newly elected. Parliament meets annually from October-December.
    • The 1991 constitution provides that the president is popularly elected. The president nominates ministers whom parliament must approve.
    • Two parliamentary committees are germane to national EPI financing. The Budget Oversight Committee works with the MoF Budget Bureau to prepare the annual budget. The Finance Committee monitors budget execution through the ministries and through MoF. In practice, oversight activities are ad hoc. One reason is that the Speaker has yet to establish a legislative calendar. Parliament receives continuing support for budget oversight activities from UNPD and the Inter-Parliamentary Union.
    • Between 2001-2005, 14 acts were approved by parliament. Both government bills and private member bills were introduced. The 2009 Appropriations Act (budget for CY 2009) was signed into law on 15 April 2009.
    • Overall governance and democracy ranking for Sierra Leone prepared by CIDA’s Office of Democracy and Governance Country Indicators for Foreign Policy Project (2007): 133/192
    • The next legislative and presidential elections will be held in August 2012 (Source: ElectionGuide).
    • The Child Rights Act (2007) establishes a National Commission for Children, which has the responsibility of assuring all children have access to health care.
    • Chapter II, Section 8 (Social objectives), Provision 3 of the 1991 Sierra Leonean Constitution states that the government will ensure that all citizens have easy access to adequate medical and health facilities.
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      Immunization Performance Indicators:*

      Percent of districts reporting at least 80% DPT3 coverage, 2008*: 40%
      % of districts with />=80% DPT3 Coverage, 2001-2008

      • *Source:
      WHO Vaccine Preventable Disease Monitoring System, 2008. Immunization Profile: Sierra Leone. Data derived from the WHO/UNICEF Joint Reporting Form, Indicator GSA17ap. "NA" indicates data not available.

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      Disease Burden:

      Population (2008): 5,560,000
      Births (2008): 223,000
      U5 Deaths (2008):
      - total 43,000
      - preventable by routine EPI: 6,0201
      - preventable by routine EPI and new vaccines: 10,7502

      (Source: UNICEF "State of the World's Children" 2009 )

      1 Assumes use of BCG, DPT, polio, and measles vaccines prevent 14% of U5 deaths.
      2 Assumes use of BCG, DPT, polio, measles, HepB, Hib, yellow fever, and pneumococcal antigen-containing vaccines prevent 25% of U5 deaths.

      Note: Vaccine preventable death estimates assume that force of infections, individual susceptibility, and probability of exposure are constant at all mortality levels.

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