Curative and preventative services for children provide the setting for a variety of interventions. Important services for children include, among others, the treatment of sepsis or pneumonia with antibiotics, of diarrhoea with oral rehydration salts (ORS), of measles with vitamin A, of malaria with Artemesinin compounds, and of wasting and malnutrition with nutritional supplements (Spectrum System, 2015).
The start of free health care for children under five brought a surge in the numbers of these children attending health facilities. In the months before the FHCI there were typically less than 100,000 consultations for under-fives each month (see Figure 62). This rose dramatically so that in May 2010 there were almost 340,000 consultations. However, the high numbers were not
sustained during the initiative’s first year and by April 2011 consultation numbers reached a low point of 120,000.
Figure 61: Number of consultations for under-fives per month
Before FHCI Ebola period 0 50000 100000 150000 200000 250000 300000 350000 400000
April 2009 April 2010 April 2011 April 2012 April 2013 April 2014 Source: Health Management Information System
Source: HMIS
The fall appears to be because people were put off using health services where these had become overwhelmed by the increase in numbers. However, in the following years the number of under- five consultations steadily grew again, so that between mid-2012 and mid-2014 monthly numbers again approached the 300,000 mark.
Regression discontinuity analysis of the 2011 SLIHS (Edoka et al., 2015) was used to look at health service utilisation by children under five compared with those over five during 2011. The expectation was that this would show a decrease in utilisation once children reached the age of five and were no longer eligible for free health care. However, the data did not demonstrate this. The explanation offered by the authors is that the boundary of eligibility for free health care is, in reality, fuzzy – and that children close to but above the boundary may still be included. In addition, we note that this analysis is based on data collection in 2011 when the HMIS data show that under-five consultations had reduced almost to pre-FHCI levels (see Figure 62). Therefore, it is not surprising that there is little difference in utilisation between under-fives and older children at this point in time. As noted above, the number of under-five consultations has steadily increased in the years since 2011.
Vaccinations are one of the key health services for young children. Only clean water performs better than vaccinations in reducing the burden of infectious diseases. The potential benefits of vaccination are widespread. For the individual, they protect against specific diseases and in many cases are very effective. In instances where correctly immunised individuals do contract diseases against which they have been immunised, the effects are often milder (Andre et al., 2007).
Children should receive their basic set of vaccinations by the age of one year. This includes BCG, measles and three doses each of DPT and polio vaccine.
The picture shown by the different sources of data for immunisation is not entirely consistent. The survey data show a large rise in fully vaccinated one-year-olds, from 41% in 2009 to 68% in 2013 (see Table 24). Figure 63 shows the HMIS monthly data for fully vaccinated one-year-olds. The trend before FHCI is erratic and the picture is unclear. But after April 2010 there is a gradual rise from around 15,000 per month up to in the region of 18,000 a month between mid-2012 and mid- 2014. This is a more modest increase than that suggested by the survey data.
Table 24: Disease prevention for children
Before FHCI After FHCI
2009 2013
One-year-olds with full vaccinations* 41 68
Use of ITNs by under-fives** 23 49
* Percentage of children aged 12 to 23 months who received all basic vaccinations at any time before the survey. ** Percentage of children under five who slept under an ITN the night before the survey.
Sources: DHSBS 2009 and DHS 2013
Figure 62: Number of children under one fully immunised each month
Before FHCI Ebola period 0 5000 10000 15000 20000 25000 30000
April 2009 April 2010 April 2011 April 2012 April 2013 April 2014 Source: Health Management Information System
Source: HMIS
The analysis by Edoka et al. (2015) confirms a statistically significant increase in the rate at which access to a complete course of DPT is growing post-FHCI, which also suggests that the FHCI may have improved access to immunisations.
In terms of equity, immunisation coverage rates between wealth quintiles were almost identical before the FHCI (see Table 25). However, by 2013 coverage rates for the lowest quintile were higher than those in the middle and wealthiest groups.
Table 25: Disease prevention for children: Equity issues
Percentage of one-year-olds* with all basic vaccinations**
Percentage*** who slept under an ITN 2008 2013 2004–2008 2009–2013 Residence Urban 40 66 30 40 Rural 40 69 24 52 Region Eastern 47 79 25 49 Northern 33 62 22 48 Southern 45 75 35 63 Western 42 56 26 27 Wealth quintile Lowest 39 73 23 50 Second 41 66 22 51 Middle 39 67 26 53 Fourth 41 69 32 51 Highest 40 62 27 35
* Percentage of children aged 12 to 23 months who received the vaccinations at any time before the survey. ** BCG, measles and three doses each of DPT and polio vaccine.
*** Percentage of children under five who slept under an ITN the night before the survey. Source: DHS 2008 and 2013
The provision of vitamin A supplements is another service typically given to children under five. This has shown a steady increase from the launch of the FHCI, when around 30,000 received supplements each month, rising to typical levels of 50,000 a month in early 2014 (see Figure 64).
Figure 63: Number of under-fives taking vitamin A supplements per month Before FHCI Ebola period 0 10000 20000 30000 40000 50000 60000
April 2009 April 2010 April 2011 April 2012 April 2013 April 2014 Source: Health Management Information System
Source: HMIS
There has been a doubling of the number of children under five sleeping under ITNs – from a quarter of children in 2009 to half in 2013 (see Table 24). The rise is particularly noticeable in rural areas: coverage rates were previously below urban areas in 2008 but the situation had reversed five years later (see Table 25).
Looking at rates by region shows that large increases have been made in children’s use of ITNs in Southern, Northern and Eastern regions. On the other hand, rates are low and unchanged in Western Area, at around a quarter in both periods.
Analysis by wealth ranking shows strong growth in under-five ITN use among the bottom four quintiles, with much lower increases for the households with the highest wealth rankings.
The DHS also provides measures that can be used to look at changes in the treatment of under- fives for pneumonia, malaria and diarrhoea. As a proxy for pneumonia, the survey looks at children who had symptoms of ARI in the previous two weeks. Among those with ARI symptoms, the proportion receiving antibiotics rose from 22% in 2009 to 45% in 2013 (see Table 26). Increases were seen in both rural and urban areas, although rural areas still lag behind in the coverage of treatment with antibiotics (see Table 27).
Table 26: Treatment for under-fives
Before FHCI After FHCI
2009 2013
Received ARI* treatment** 22 45
Received antimalarial drugs for fever*** 38 48
Received treatment for diarrhoea*** 72 86
* ARI symptoms (cough accompanied by short, rapid breathing which was chest-related or difficult breathing which was chest-related) are considered a proxy for pneumonia.
** Percentage of children under five with symptoms of ARI in the two weeks preceding the survey who received antibiotics.
*** Percentage of children under five with a fever in the two weeks preceding the survey who received antimalarial drugs. **** Percentage of children under five with diarrhoea in the two weeks preceding the survey who received oral
rehydration therapy.
Sources: DHSBS 2009 and DHS 2013
Table 27: Treatment for under-fives: Equity issues
Percentage* with ARI*** symptoms who
received antibiotics
Percentage with fever* who took antimalarial drugs
Percentage* with diarrhoea who were
given oral rehydration therapy (ORT) 2008 2013 2008 2013 2008 2013 Residence Urban 41 59 35 45 79 87 Rural 25 42 28 50 72 86 Region Eastern 18 60 23 60 68 87 Northern 25 40 26 46 74 84 Southern 33 44 44 48 72 90 Western 47 52 32 37 81 89 Wealth quintile Lowest 26 38 27 49 61 89 Second 20 50 29 47 74 87 Middle 27 34 29 49 75 83 Fourth 24 53 29 51 80 84 Highest 56 64 37 44 80 88
* Percentage of children under five with the stated symptoms in the two weeks preceding the survey who received treatment.
** ARI symptoms (cough accompanied by short, rapid breathing which was chest-related or difficult breathing which was chest-related) are considered a proxy for pneumonia.
Source: DHS 2008 and 2013
At a regional level, Eastern Region has shown a dramatic increase from 18% receiving antibiotics in 2008 to 60% in 2013. This increase is far higher than other regions and has transformed it from the worst to the best performing region. The pattern appears to be driven by extremely high rates in Kono district, although the sample size at the district level is relatively small so this finding should be treated with caution.
The presence of fever is considered a proxy for malaria. Among children under five years who had had a fever in the two weeks before the survey, the percentage who took antimalarial drugs
increased from 38% in 2009 to 48% in 2013. In addition, rural areas have overtaken urban areas during this period (see Table 26).
As with treatment for ARI, Eastern Region stands out as moving from the worst performer in 2008 (23% receiving antimalarial drugs) to the best in 2013 (60%). Rates are high in all three of the Eastern Region districts: Kailahun, Kenama and Kono.
Variation in coverage is low between wealth quintiles in 2013, with all groups showing around half of children with fever taking antimalarials.
Dehydration caused by severe diarrhoea is a major cause of morbidity and mortality among young children, although the condition can be relatively easily treated with ORT. Table 26 shows that the percentage of children with diarrhoea in the two weeks before the survey that were given ORT increased from 72% in 2009 to 86% in 2013.
In the earlier period there were some variations between different areas and groups, with those in rural areas, in Eastern Region and in the lowest wealth quintile having lower rates than others (see Table 27). By 2013 the pattern was much more even, with all areas and groups showing rates between 83% and 90%.
6.1.5
Summary
There have been clear improvements in the coverage and uptake of services in recent years. Some of these appear to have started before the launch of the FHCI, but there have also been positive changes since the start of the initiative. In many cases the gap in coverage between geographical areas and wealth groups has closed significantly.
Basic ANC is now near universal in Sierra Leone. The improvement in overall coverage appears to have been predominantly before the FHCI. ANC coverage is also now more equal, with
improvements particularly seen in rural areas, the Northern Region and the lowest two wealth quintiles. The gap in coverage between groups has virtually disappeared in many aspects of ANC.
Protection from malaria during pregnancy has increased greatly from before the FHCI. The
proportions of pregnant women using ITNs and taking protective treatments for malaria both more than doubled between 2009 and 2013.
Births in a health facility remain low by international standards but there have been improvements. These started before the FHCI, but there has also been growth in the numbers since 2010,
reaching 57% of all births in the period 2010 to 2013. The picture is similar for births that are attended by a skilled health worker, with improvements both before and after the FHCI. However, in terms of equity, the lowest three quintiles and the Northern Region still lag behind in both health facility deliveries and those attended by a skilled health worker.
Coverage of PNC has improved since the start of the FHCI, with the administrative data in
particular showing strong growth: numbers of first PNC appointments rose by 50% between 2010 and 2014. The gap between geographical areas and wealth groups has also narrowed.
The FHCI brought a surge in the number of consultations for under-fives at health facilities. The numbers more than tripled immediately after the launch to over 300,000 consultations in one month in May 2010. Numbers then declined rapidly, probably because the facilities struggled to cope with the increased demand, but by 2014 the number of under-five consultations was once again approaching the 300,000 per month mark.
The picture for child immunisation rates shows improvements, although the size of these is less clear. The survey data show strong growth in fully vaccinated children under one. On the other hand, the administrative data show more modest growth after the FHCI, although this data source is likely to be weaker than the survey. The lowest wealth quintile group has seen the most
improvements: before the FHCI rates were fairly even across groups, but the latest figures show the bottom wealth quintile now has higher rates than others.
The use of ITNs by children under five years old more than doubled between 2009 and 2013. The growth was particularly noticeable among those in rural areas and the bottom four wealth quintiles.
Treatment rates for children under five for pneumonia, malaria and diarrhoea all appear to have improved in the years following the FHCI. In particular, the proportion of children under five with symptoms of ARI (a proxy for pneumonia) that were treated with antibiotics doubled to 45% in 2013 compared to just before the FHCI. Eastern Region in particular showed great improvements moving from the worst region to the best during this period. This pattern for Eastern Region was also seen in improvements in malaria treatment for these children.