International Journal of Gynecology and Obstetrics 135 (2016) 380384

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International Journal of Gynecology and Obstetrics

journal homepage: www.elsevier.com/locate/ijgo

EVIDENCE FOR ACTION

Using evidence to strengthen accountability for health nancing in

Sierra Leone
Sowo A. Lebbie a,, Rosanna Le Voir b, Joanna Tom-Kargbo c, Mohamed Drissa Yilla a,
Abu Bakarr Kamara d, Sara L. Nam b
a
Evidence for Action, Options Consultancy Services Ltd, Freetown, Sierra Leone
b
Evidence for Action, Options Consultancy Services Ltd, London, UK
c
Save the Children, Freetown, Sierra Leone
d
Budget Advocacy Network, Freetown, Sierra Leone

a r t i c l e i n f o a b s t r a c t

Article history: In 2012, the government of Sierra Leone cut the national budget allocation to the health sector. Civil society
Accepted 14 September 2016 organizations planned a nationwide health budget advocacy campaign, coinciding with the 2012 general
elections, to hold future leaders to account on nancing for womens and childrens health. As part of the
Keywords: campaign, Evidence for Action produced district health budget tracking scorecards. The scorecards presented
Accountability
Ministry of Finance data on the allocation and disbursement of health funds in each district. The data were commu-
Evidence for Action (E4A)
Health nancing
nicated using simple, non-technical language so that citizens could understand the key messages and take action.
Maternal, newborn and child health A total of 5600 scorecards were shared at district electoral forums attended by political candidates, community
Political will members, and health activists. Since the election, the proportion of the total government budget allocated to health
Sierra Leone increased from 7.4% in 2012 to 11.2% in 2014. However, transforming politicians commitments and pledges into
Scorecards implementation has been challenging, conrming that accountability is a long-term process.
Budget Advocacy 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction
In November 2012, Sierra Leoneans voted in general elections for
their new national, district, and ward representatives. The election
was a key opportunity to hold future leaders to account on nancing
for womens and childrens health, since parliamentarians depended
on citizens for their vote. As part of a coalition among civil society
organizations, the Evidence for Action (E4A) program worked with
fellow members of the Budget Advocacy Working Group (BAWG) on a
major health budget advocacy campaign. The campaign called for
increased allocation, efciency, and transparency of spending for
mothers and babies in Sierra Leone, pushing politicians to make
commitments on health nancing in the build-up to the election. The
campaign was led by Save the Children, Budget Advocacy Network,
and the Freetown Water, Sanitation and Hygiene (WASH) Consortium.
Despite the introduction of the Free Health Care Initiative in 2010
and related sensitization activities, many citizens were not initially
aware that their elected representatives had a responsibility to ensure
that pregnant women, lactating mothers, and children under ve had
Corresponding author at: Evidence for Action, 16 Kosonelli Drive, Off Spur Loop,
Freetown, Sierra Leone. Tel.: +232 76 648697.
E-mail address: slebbie@options-sl.org (S.A. Lebbie).
a right to access free health care. Similarly, many people did not know
that the government had committed to allocate 15% of the annual
national budget to health as part of the Abuja declaration [1], that this
promise had not been fullled (Fig. 1), or that disbursements were
often late or incomplete [2]. Moreover, voting behavior in Sierra Leone
is not typically issue-based. BAWGs campaign aimed to strengthen
accountability for health budgets by engaging citizens around these
issues immediately before the election so that citizens could take the
issues into account in their voting considerations.
2. Description of the case
A budget cut made by the government of Sierra Leone to the health
sector from 11% in the 2011 national budget to 7.4% in the 2012 budget
led to a growing movement among civil society to advocate for the
government to meet its commitment to the Abuja Declaration [3].
The civil society organizations who came together as BAWG aimed to
strengthen advocacy efforts to call upon the government to ensure
transparent and accountable planning of health budgeting that was
gender-sensitive and pro-poor [4].
In collaboration with government, local councils and hospitals across
the country, the civil society coalition undertook a nationwide health
and sanitation budget tracking exercise in 2012, building on a pilot
conducted in 2011. The purpose was to determine what investments

http://dx.doi.org/10.1016/j.ijgo.2016.10.001
0020-7292/ 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
 S.A. Lebbie et al. / International Journal of Gynecology and Obstetrics 135 (2016) 380384
Fig. 1. Annual government allocation to health as a proportion of total government budget, 20092013, based on gures provided by the Ministry of Finance and Economic Development
[5,6].
and expenditure had actually been made in health and sanitation
from national government down to local councils, District Health
Management Teams (DHMTs), hospitals, and peripheral health units.
Key to the success of this process was the early and constructive
engagement by civil society with representatives of the Ministries of
Health and Sanitation (MoHS) and Finance and Economic Development
(MoFED). The budget tracking method was presented and dialogue
on how the ndings could facilitate advocacy for increased health
allocation and effective expenditure took place [4].
E4A supported data cleaning and packaging of evidence provided by
the local councils and MoFED and collected by Save the Children, Budget
Advocacy Network, Freetown WASH Consortium, and World Vision.
Findings revealed that record keeping was poor and there were
often large amounts of funding unaccounted for. Further, there were
discrepancies in health disbursements per person across districts, up
to as much as a ten-fold difference [7].
On behalf of the civil society coalition, E4A developed district health
budget tracking scorecards to summarize the key ndings for all 14 dis-
tricts [7]. The scorecards showed progress in the allocation and dis-
bursement of health funds at different levels in each district, and how
districts performed relative to others. This information was communi-
cated in simple, non-technical language, driving citizens to raise their
voices for action and accountability (Fig. 2).
The district health budget tracking scorecards informed community
members of their rights and of parliamentarians responsibilities,
as well as raising citizens awareness and expectations about key
health nancing issues. They outlined district-specic differences
between the money allocated to the DHMTs and the money actually
received. For example, in Bo in 2011, the Council was reported to
have transferred 26 770 million Leone (around US $6.08 million
based on 2011 currency conversion rates); however, the DHMT
reported receiving only 514 million Leone, leaving approximately
98% unaccounted for [7]. The scorecards included citations showing
that the data came from the MoFED; these references validated the
evidence and equipped citizens with the agency to hold politicians to
account through their vote.
In total, 5600 scorecards were shared at electoral forums in each dis-
trict across the country in October and November 2012. These forums
brought together candidates from a range of political parties standing
for election to district councils and parliament, with community mem-
bers and health activists. They provided a space for decision-makers
and citizens to discuss plans for health service delivery and issues
relating to health nancing face-to-face. The scorecards were tools to
hold politicians to account and to press for more funds, better record
keeping and better planning of health budgets. Importantly, they pro-
vided information on what citizens could call upon their local
381
candidates to promise if elected. The forums were recorded and aired
by community radio stations so those unable to attend could still access
the information via the radio. Health Alert, a local civil society group,
was at the forefront of community engagement and mobilization of cit-
izens voices. The district electoral forums were complemented by sim-
ilar engagements in parliament.
The success of the scorecards was underpinned by activities across
the wider campaign, led by Save the Children, which enabled activists
and citizens to use the evidence for advocacy and accountability. Locally
recruited activists developed pledge cards outlining district-specic
demands and a cross-cutting health nancing request. These helped
to focus citizens' and politicians calls for better health nancing on a
specic and practical set of policy objectives, encouraging politicians
to make relevant, concrete commitments. For example, in Western
Urban area, the pledge card called for a functioning latrine in each of
the peripheral health units in the district; procurement of additional
ambulances that were functional and fueled; improved nancial record
management; and full disbursement of allocated funds. Candidates
signed the pledge cards and their commitments were broadcast on TV
and local radio stations. Citizens also signed petitions, and a common
Health Manifesto was shared with the six main political parties from
March 2012, calling for a clear plan to achieve the Abuja target by
2015 and for the Free Health Care Initiative to be sustained.
3. Results
Sharing the scorecards at district electoral forums meant voters had
access to evidence of nancial mismanagement in their district and the
opportunity to hold leaders to account for their actions in person.
In total, 62 candidates and around 750 citizens attended the district
electoral forums across the country with the broadcasts of the forums
reaching many more communities. The petitions, pledge cards, and
radio shows also helped to inform citizens of their rights and of parlia-
mentarians responsibilities, strengthening the likelihood of future
activism. For example, when it was announced shortly after the election
that the health budget had been decreased, hundreds of women were
mobilized by local organizations and travelled to State House to protest.
Five out of the six political parties signed the Health Manifesto and 68
parliamentary candidates signed pledge cards.
The combined effects of increased citizen engagement and politi-
cians commitments have begun to show in government policy. Since
the election, the Free Health Care Initiative has been sustained, and
although the Abuja target has not been met, the governments health
budget has increased from 7.4% in 2012 to 10.5% in 2013 and 11.2%
in 2014 [6]. Some requests in the district pledge cards have also been
fullled. For example, in Kono district, a pediatric ward was completed
382 S.A. Lebbie et al. / International Journal of Gynecology and Obstetrics 135 (2016) 380384

Fig. 2. Example of a district health budget tracking scorecard for Bo district, 2012 [7] (front and back). Reproduced with permission granted by the Budget Advisory Network and Save the
Children.

and a new generator was purchased. However, there are ongoing chal-
lenges related to the full and timely disbursement of funds from nation-
al to district and facility levels [2], issues around which E4A and BAWG
continue to advocate [8].
4. Challenges and lessons learned
Not surprisingly, transforming politicians commitments and pledges
into implementation after the election has been challenging. The coali-
tion has learned that carefully targeted one-to-one engagement with
powerful stakeholders, such as the Minister of Finance and other cabinet
ministers, would be a useful complement to a future public facing cam-
paign. Also, investments in advocacy must be kept up following the elec-
tion to close the accountability loop. Finally, in a context where voting is
not issues-based, strengthening accountability is a long-term process.
One of the key strengths of the campaign was how it successfully
combined the different ingredients required for accountability. The score-
cards communicated easily understandable evidence of the problem
to the citizens holding decision-makers to account through elections.
The campaign then provided a space for citizens to use the evidence
by engaging with decision-makers on these issues, and specied con-
crete commitments for politicians to sign up to. BAWG also effectively
harnessed its members different skills to maximize the success of the
campaign. For example, E4A analyzed, packaged, and communicated
health nancing information so that citizens could understand it and
take action.
Author contributions
SAL provided technical leadership and guidance for E4As contribu-
tion to the campaign and signicantly contributed to development of
 S.A. Lebbie et al. / International Journal of Gynecology and Obstetrics 135 (2016) 380384
Fig. 2 (continued).
this case study, drafts, review, and approval of all versions. RLV led the
development of this case study, drafted the manuscript, and reviewed
and approved all versions. JTK provided content and inputs to drafts,
and reviewed and approved all versions. MDY provided strategic over-
sight to E4As involvement in the campaign, contributed to drafts, and
reviewed and approved all versions. ABK provided technical expertise
to the budget tracking processes, contributed to drafts, and reviewed
and approved all versions. SLN provided technical oversight to E4As
involvement in the campaign including leading on the design of the
scorecards, critically revised and contributed to drafts, and reviewed
and approved all versions.
Acknowledgments
The Evidence for Action programme in Sierra Leone was funded
by the UK Department for International Development (DFID). The
authors thank Ali Readhead, EVERY ONE Campaign Manager, Save
the Children Sierra Leone, for her oversight of the budget advocacy
383
election campaign, and to Giovanna Lauro and Aurlie du Chtelet
formerly of Evidence for Action for their technical inputs to the review
of health budget tracking data analysis and design of scorecards.
Acknowledgements are also extended to Laura Sochas of Evidence
for Action for her review and advice to the manuscript. Funding for
Save the Childrens activities came from the Newborn and Child Survival
Breakthrough Funding.
Conict of interest
Sowo Lebbie, Rosanna Le Voir, Mohamed Yilla, and Sara Nam were
supported by the DFID-funded Evidence for Action (E4A) program.
References
[1] The Organization of African Unity. Abuja Declaration on HIV/AIDS, Tuberculosis and
Other Related Infectious Diseases. OAU/SPS/ABUJA/3. African Summit on HIV/AIDS,
Tuberculosis and Other Related Infectious Diseases; April 2427, 2001. http://www.
un.org/ga/aids/pdf/abuja_declaration.pdf.
384 S.A. Lebbie et al. / International Journal of Gynecology and Obstetrics 135 (2016) 380384
[2] Budget Advocacy Working Group. Bottlenecks in the Disbursement of Government
of Sierra Leone Funds to Health and Water Resources Sectors 2010-2013. Freetown:
BAG; 2015. http://www.mamaye.org.sl/sites/default/les/evidence/Bottleneck%20
Report%20-%20Dec%202014.pdf.
[3] Save the Children. Health Sector Budget Advocacy: A guide for civil society organiza-
tions. London: Save the Children; 2012.
[4] Save the Children. Health Policy Action Fund Report. Prepared by A. Readhead,
EVERYONE Campaign Manager, Save the Children. Published 2012.
[5] Save the Children. Sierra Leone Health and Sanitation Budget Tracking 2012.
Freetown: Save the Children; 2012. https://www.savethechildren.org.uk/sites/
default/les/docs/Sierra_Leone_Health_and_Sanitation_Budget_Tracking_2012.pdf.
[6] Ministry of Finance and Economic Development [Sierra Leone]. Government of
Sierra Leone Annex 1 Budget Prole for FY 20112015. Freetown: MoFED; 2012.
http://mofed.gov.sl/speeches/prole%202013-15.pdf.
[7] Evidence for Action. Health Budget Tracking Scorecards. http://www.mamaye.
org.sl/en/evidence/health-budget-tracking-scorecards. Published 2012. Accessed
September 3, 2015.
[8] Sallieu S. BAG Launches Report on Late and Incomplete Disbursement of Funds
for Health and Water in Sierra Leone. http://www.mamaye.org.sl/en/blog/bag-
launches-report-late-and-incomplete-disbursement-funds-health-and-water-sierra-
leone. Published 2015. Accessed September 3, 2015.