Sierra Leone has some of the highest maternal and child mortality rates globally and has limited capacity to effectively monitor Quality of Care (QoC) within reproductive, maternal, newborn, child, and adolescent health (RMNCAH).[1] This is due to a lack of essential QoC indicators in the national health information system and inadequate data utilization mechanisms for quality improvement (QI). This challenge, however, is not unique to Sierra Leone and led to the establishment of the QoC Network in 2017.[2] This coalition, comprised of government bodies, implementing partners, and donors from 11 countries, is dedicated to improving QoC to decrease preventable maternal and child mortality. Within the network’s activities, WHO Sierra Leone partnered with national authorities to integrate critical QoC indicators into the national health information system. This integration enables routine monitoring of health trends and outcomes in line with the QoC objectives. Now, key maternal and neonatal health (MNH) QoC indicators are systematically collected and reported, promoting a culture of data-driven change management and accountability in QoC practices.

How did Sierra Leone, with the support of WHO, achieve this?

The QoC Network, guided by four strategic pillars—Leadership, Action, Learning, and Accountability (LALA)—is committed to improving RMNCAH outcomes. In 2018, the Network’s WHO-based Secretariat conducted an in-country mission in Sierra Leone, focusing on guiding health officials in the MNH QoC monitoring framework, evaluating the health information system's (HIS) preparedness for MNH QoC metrics, and fostering policy discussions. The mission highlighted areas for HIS improvement.

Responding to these insights, the Network’s WHO-based Secretariat devised technical solutions and recommendations for MNH QoC measurement. These included a specialized MNH QoC monitoring framework, data collection instruments, reporting tools, and QI project templates. WHO Sierra Leone assisted the Ministry of Health and Sanitation (MoHS) in tailoring the QoC Network's framework to Sierra Leone’s specific context. This adaptation involved adding new QoC monitoring indicators to the original set of 15 core indicators in DHIS2, facilitating their monthly collection and reporting. WHO also aided in developing an RMNCAH scorecard and revising data collection tools, such as health facility registers and patient records, to gather essential data.

WHO's technical support extended to the creation of an indicator dashboard within DHIS2, improving data accessibility and system accountability. This dashboard allows for benchmarking, highlighting performance variations across the health system.

^{A WHO-led national training programme was held in November 2022 to build the capacity of 20 national assessors around the structure and use of the WHO’s Maternal and Newborn and Paediatric and young adolescent hospital quality assessment and improvement tools.}
Photo credit: WHO Sierra Leone

Capacity building was prioritized through a WHO-led 5-day workshop aimed at enhancing technical, leadership, management, and coordination skills among newly appointed QoC officers and monitoring and evaluation officers. This training, which included site visits to assess the needs of and provide guidance to healthcare institutions, was further disseminated by trainees through a cascade training model. In 2022, a 12-day national training by the WHO-based Secretariat prepared 20 national assessors for the 2023 national quality assessment using WHO’s quality assessment and improvement tools for maternal, newborn, paediatric, and young adolescent hospital care. 

In 2023, the WHO-based Secretariat embarked on a two-week mission to support MoHS in implementing 25 global core paediatric and young adolescent QoC indicators. The mission focused on orienting the MoH and partners on these indicators, assessing readiness for data collection and reporting, strategizing the operationalization of uncollected indicators in the HIS, and documenting lessons for future scalability. 

QI teams at district and facility levels now gather data on service quality and intervention outcomes, identifying service gaps for targeted response plans. Notably, in 2019, 11 out of 12 QI projects across various facilities achieved their goals. The following year saw 11 QI projects implemented in health facilities, of which eight met their objectives.

In 2022, the Network’s WHO-based Secretariat used a limited set of core QoC indicators to evaluate the QoC programme. Preliminary results showed notable decreases in pre-discharge neonatal mortality and obstetric case fatality rates, though the institutional stillbirth rate remained constant over the 5-year period evaluated. While direct causal links to specific QoC initiatives are challenging to establish, these improvements are promising signs of the overall impact of the QoC network's efforts.

WHO's ongoing technical support and capacity-building initiatives continue to bolster QoC enhancements for RMNCAH in Sierra Leone, laying the groundwork for sustained healthcare improvement.