Rights on Paper and Care at the Bedside: Reading Sierra Leone’s RMNCAH Policy

What the policy promises

The two central documents are the RMNCAH strategy for 2017 to 2021 and the Quality of Care Roadmap for 2020 to 2024. The strategy sets the baseline numbers that planners work from: at the time of drafting it recorded a maternal mortality ratio of about 1,165 deaths per 100,000 live births, under-five mortality of 156 per 1,000, and neonatal mortality of 39 per 1,000. It attaches targets and a five-year costing, modelling, for example, a reduction of maternal deaths to 650 per 100,000 by 2021 under a fully funded scenario, with a total cost running into the hundreds of millions of dollars. Those figures are not decoration. They are what a budget is measured against, and what a court or an auditor can point to when the state falls short of its own plan.

The Free Health Care Initiative, launched in 2010, removed user fees at the point of care for pregnant women, breastfeeding mothers and children under five. It runs through the health plans that followed and remains the concrete entitlement a mother can assert at a public facility. The Quality of Care Roadmap then raises the bar from access to standard: care is meant to be safe, timely, respectful and grounded in evidence, with named responsibilities at facility and district level. Anyone claiming their rights should cite the two together, the Free Health Care entitlement for the promise of free treatment, and the Roadmap for the promise that the treatment will be adequate.

Where policy and practice collide

The strategy costs its own plan and then admits the gap: the targets are only met if the money and the staff arrive. The Roadmap concedes that quality is uneven, listing audits, infection prevention, referral and supply chains as recurring weak points. In practice this means a woman can be entitled to a free delivery and still leave a clinic in danger because the drugs are out of stock, the skilled attendant is absent, or the referral fails. These are not merely administrative lapses. They are failures against commitments the state has made in law and policy, and that is what makes them contestable.

Three facts give an advocate something to hold. First, the policy commits the state to measurable targets and to systems, maternal death surveillance and response, and perinatal review, that generate their own evidence. That paper trail can be tested in an audit or a courtroom. Second, the financing plans repeatedly quantify a shortfall, which tells advocacy exactly where to aim: budget lines and donor alignment. Third, the Free Health Care entitlement is not unlimited. Adolescents who are not pregnant or breastfeeding generally fall outside its financial protection, which leaves a real gap in adolescent sexual and reproductive health that policy has named but not closed. The documents, in other words, create both rights and gaps. The work is to make the rights effective and to shrink the gaps with budget and regulation.

Money, accountability and the role of oversight

The strategy’s costing produced a clear estimate of what five years would require, and showed how domestic resources and partner commitments together fall short. Where budgets are thin, the results are predictable: unpaid staff, empty shelves and underfunded referral networks. The useful move is to connect that costing to the annual budget and to the rules that decide who funds and runs peripheral health units, so that a procurement failure or a delayed transfer becomes something specific that can be challenged or fixed rather than a vague misfortune.

The tools for that already sit inside the policy stack: surveillance reports, the health information system, annual quality reviews, and partner funding statements. The method is evidence-led enforcement. Ask the Ministry or a district health team to produce its surveillance findings and to show how funds were spent against the RMNCAH costing. Where preventable deaths in facilities continue and the record shows neglect, persistent stockouts at clinics that are supposed to receive Free Health Care grants, for instance, that is a strong basis for a remedial order or a corrective plan with monitored milestones. The Roadmap’s own emphasis on clinical audit and near-miss review hands courts and oversight bodies a ready-made standard to measure against.

The bottom line

Sierra Leone does not lack policy or entitlements. What remains is the harder task of turning them into routine practice at every peripheral health unit, which takes money, staff, honest audit and pressure from outside the system.

Because the strategy itself supplies the numbers and names the procedures, there is little room to treat these failures as vague. The law and the policy give precise handles for reform, and the job is to use them.

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