What can we learn from Sierra Leone?


When looking at the figures in terms of food safety, disease prevalence, undernutrition, and general well-being, sub-Saharan African countries are consistently found at the bottom end of the health spectrum. One of these countries, Sierra Leone, is of the poorest in the world. It has a population of over 7 million, but gross national income per person sits at only $1 per year. Though there is still huge scope for improvement in health care in Sierra Leone, there are some things we can learn from the health profile and management of disease in this country over the past couple of decades.

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Sierra Leone Health Profile May 2016
Source: WHO

A recent study by Carvajal-Vélez et al. evaluated the quality of diarrhoea management in 12 sub-Saharan African countries, classifying each country’s source of care using WHO and UNICEF recommendations as ‘good’, ‘fair’ or ‘poor’. In 11 out of the 12 countries included in the study, only 17-38% of children received ‘good’ quality care. Interestingly, in Sierra Leone, over 67% of children with diarrhoea received high quality care, and only 10% of care was classified ‘poor’. Country ORS coverage is an important indicator of the quality of diarrhoea care. ORS use was a mere 17% in Cote d’Ivoire and Cameroon, and less than 50% in the rest of the sub-Saharan Africa. Sierra Leone, is the exception again, with an ORS coverage of 85% in 2013. Sierra Leone is no doubt a standout, with by far the highest level of care in sub-Saharan Africa. What has caused this exceptional result?

The answer is somewhat unexpected. From 1991-2002, Sierra Leone was struck by civil war. This resulted in a displacement of 2 out of 5.5 million people, and placed a huge stress on the health infrastructure at the time. This led to an opportunity to rehabilitate the primary health care system, supported heavily by international donors. During the war, a huge proportion of people were concentrated in population camps. Resulting cholera outbreaks called for increased ORS availability and accessibility. Prior to the war, community ‘Blue Flag Volunteers’ were trained with hygiene promotion and the use and dispersal of ORS, though these members became of particular importance during the time of unrest to improve the availability and accessibility of ORS.

Schoolchildren pick up oral rehydration salts distributed by USAID/OFDA grantee Mercy Corps at a community cholera awareness activity near Mirebalais, Haiti, on Jan. 26, 2011
Source: USAID

Integrated community case management of childhood illness began shortly after the war, and people learned about ORS for treating dehydration. This was through effective campaigning for the use of ORS by direct communication with active community promoters. Continued effort was also made for the supply of ORS – the Ministry of Health and Sanitation increased tracking density of ORS distribution, district communities were given the responsibility to order supplies, and supervisors monitored re-stocking of ORS in Community Based Distributor (CBD)’s kits. More recently, in April 201, free services for pregnant or breastfeeding women and children below 5 were introduced, and as a result more women and children are getting access to health centres.

Mother and baby queuing for a Children’s hospital to open in Sierra Leone 
Source: DFID

Even in Sierra Leone, a country that ranks 181st out of 187 countries in the Human Development Index, simple strategies have shown to be effective in improving the management of disease. Increased community involvement and education, as well as government support, has resulted in significant scaling up of ORS and other basic child health services. It just goes to show how co-operation and co-ordinated planning and management can lead to big improvements in the countries that need it most. The time for change, and the time for global action, is now.


  1. Strengthening Health Outcomes through the Private Sector (US). Sierra Leone ORS Case Study (Internet). Bethesda: Strengthening Health Outcomes through the Private Sector (US); 2012 Nov (cited 2017 Feb 23). Available from: http://www.shopsproject.org/resource-center/sierra-leone-ors-case-study
  2. Carvajal-Vélez L, Amouzou A, Perin J, Maïga A, Tarekegn H, Akinyemi A, Shiferaw S, Young M, Bryce J, Newby H. Diarrhea management in children under five in sub-Saharan Africa: does the source of care matter? A Countdown analysis. BMC Public Health. 2016 Aug 19;16(1):830.
  3. Wilson SE, Morris SS, Gilbert SS, Mosites E, Hackleman R, Weum KL, Pintye J, Manhart LE, Hawes SE. Scaling up access to oral rehydration solution for diarrhea: Learning from historical experience in low–and high–performing countries. J glob health. 2013 Jun 1;3(1):010404.
  4. World Health Organization. Sierra Leone: Country health profile [Internet]. Geneva: World Health Organization; 2015 [cited 2017 Feb 23]. Available from: http://www.afro.who.int/en/sierra-leone/country-health-profile.html

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