POLICY BRIEF

AID ACCOUNTABILITY IN SIERRA LEONE’S HEALTH

SECTOR AND MECHANISMS FOR EFFECTIVENESS
INTRODUCTION
The ability of citizens to demand accountability and
more open government is fundamental to good
governance. Ensuring there is growing recognition of
the need for new approaches to tripartite aid
accountability where donors and recipient governments
are answerable to their citizens. The Paris Declaration
recognises the need to enhance donor and recipient
government accountability to their citizens and
parliaments, the importance of timely and transparent
information on aid flows, and the need to advance
mutual accountability.
In response to adhering to the fundamental principles
of the Paris Declaration, the government of Sierra
Leone, as part of its engagement strategy with
development partners, a Mutual Accountability
Framework (MAF) was adopted in 2014. Therefore, the
Paris Declaration highlights the critical significance of
providing a more comprehensive understanding of how
Aid Effectiveness contributes to meeting development
objectives and, in this case, – Health. The Accra Agenda
for Action reiterates the importance of the
implementation of the Paris Declaration in 2010. This
report assessed the relevance and effectiveness of the
Paris Declaration and its contribution to aid
effectiveness and ultimately improved delivery of
essential services in a transparent and accountable
manner.
In recent years, donors have recognised the
importance of ensuring that these frameworks
support nationally-owned poverty reduction
strategies or similar approaches to improve people's
lives. Different objectives and interests between
donors and partner governments can impair aid
effectiveness in the health sector; more so in some
instances donor support can be opaque and
unpredictable. The way aid is delivered can create an
unnecessary burden on partner countries, hinder
efforts to build partner country capacity and weaken
partner government leadership and its accountability
to its people.
In a bid to better understand the current status of aid
accountability and effectiveness landscapes in Sierra
Leone's health sector, a Consortium of three partner
agencies; Budget Advocacy Network (BAN), Water,
sanitation and Hygiene Network (WASH-Net) and
Health Alert Sierra Leone (HASL) through funding
from the Open Society Initiative for West Africa
(OSIWA) are leading this maiden process aiming at
promoting mutual aid accountability especially in the
health sector and to shift the conversation on
conventional aid arrangements.

METHODS AND MATERIALS

A mixed data collection approach (quantitative and qualitative) was used to address the objectives and the scope
of work. Two (2) data collection methods were used: primary data collection, in-depth interviews and discussions,
and secondary data collection. Relevant primary information was shared in terms the key actors to target for the
primary data collection; developed survey instruments on the status of indicators of the Paris Declaration and
the systems, processes and procedures in implemented donor health funds, including mode of reporting on
outcomes of the implementation of health programmes; conducted key Informant Interviews (KIIs) using the
structured survey instruments to the different categories of stakeholders.
Secondary data was collected from diverse sources and review the relevant documents and existing literature on
aid and accountability in the health sector in Sierra Leone. The study further reviewed identified multilateral,
bilateral and INGOs projects in the health sector regarding the number of health projects implemented by which
donor; the size of the project portfolio; project development objectives etc.

1|Page
 The Health Accountability Project

In terms of the institutions targeted, the primary source of donors the report covered are IPAU, Ministry of
Health & Sanitation, Ministry of Finance, Global Fund, Against Tuberculosis, Aids and Malaria International
NGOs, UN agencies like UNICEF, World Vision and local NGOs and service delivery agents (District Health
Management Teams etc.). The extent to which the government is able to track down systems, processes and
procedures of the health funds flow from all these institutions along the value chain is critical to addressing the
accountability in aid to the health sector in Sierra Leone. The study covered the period pre- and post-Ebola (2013
PARENT
to 2018) TEACHERS
and the period of the COVID-19 pandemic (2020).
ASSOCIATION 20XX
KEY FINDINGS
In summary, from the institutions targeted, the following were noted
a) It is evident that data is available for on-budget aid, especially direct budget support with the exception
of on-budget assistance that comes through the Integrated Health Projects Administration Unit (IHPAU)
especially for sub-components that relied on stakeholders for implementation.
b) Overall, accountability in aid relationships continues to be skewed towards donors, with minimal
opportunities for downstream accountability. Moreover, the aid-dependent nature of Sierra Leone
contributes to privileging donor concerns over citizens’ voice.
c) Programmes implemented by bilateral agencies Global Fund) and International Non-Governmental
Organisations (INGOs) have to some extent in line with national priorities and more importantly, the
intended purposes for which the institutions were set up and operates. The same pattern flows for local
Non-Governmental Organisations (NGOs).
d) These institutions (bilateral agencies, INGOs) attract multiple levels of funding accompanied by some
tight provisions on programme spending; meaning there is no flexibility on how programmes tied to
specific programmes could be revised and, where applicable, the administrative processes to achieve such
are complex.
e) It is not clear how reporting is done directly to the government. Government Ministries, Departments
and Agencies (MDAs) involvement in the programmes of local and international NGOs is not a sufficient
condition to conclude reporting on outcomes of programme implementation in-country. One may be
convinced that publications of the strategic plans of local and international NGOs and their annual
reports suffice as reporting to the government. However, specific indicators that may be considered in
full disclosure of reporting requirements may not be explicitly presented in the annual reports. For
instance, the amount of funds spent on specific programmes and the nature of programme
implementation by the local NGOs regarding operational costs, including consultancies, travels etc.,
could not be readily available in the publications. In short, transparency of information for off-budget
aid is problematic.
f) District Medical Officer (DMOs) and Medical Superintendents interviewed further noted that vertical
funds have limited in-built flexibility to adapt to changing needs on the ground and are unlikely to
conform to the absorption capacity to local NGOs sufficiently. Application procedures, reporting and
review mechanisms are bureaucratic, time-consuming and not coordinated, creating operational
problems exacerbated by limitations on funding for administrative purposes.
g) It was clear that bilateral donors have funded specific health programmes (Malaria, Tuberculosis etc.)
through the District Health Management Team (DHMT). The DHMTs have directly utilised those funds
with little or no attention to the content of the approved annual health plans directly funded by the
government, which may also capture similar activities for implementation.
h) The key institutions, in theory – Development Aid Coordination Office (DACO) in the Ministry of
Planning and Economic Development (MoPED) and the Service Level Agreement (SLA)-Unit in the
Ministry of Health and Sanitation (MOHS) who were established to ensure bilateral donors and INGOs
are accountable in aid administration and report on the outcomes of aid implementation via their
respective channels could not provide the relevant information needed for the report. This is attributed

2|Page
 The Health Accountability Project

to a lack of central government funding to these institutions especially DACO, and possibly inadequate
human capacity to expand the scope of operations to the proliferation of local and internal NGOs in the
country.
i) Across various agencies assessed, weak Parliamentary oversight was identified on the use and
effectiveness of aid financing in Sierra Leone.
PARENT TEACHERS
KEY RECOMMENDATIONS
ASSOCIATION 20XX Partners:
Donors and Development
a) Aid accountability needs to shift from domestic actors in donor countries to the beneficiaries of recipient
countries to better respond to their needs and priorities.
b) Donors need to reconcile their focus on short-term development impact with the long-term institutional-
building required to ensure development impact is sustainable at the level of the recipient country.
c) Understanding how institutions change over time and contributing to development results is vital to
move away from a narrow focus on short-term impact. Other measures to fix incentives within donor
agencies and promote bottom-up planning and country-based dialogue can shift the dimensions of aid
accountability in the right direction.
d) Donors must endeavor to align their development aid with the country’s development plans and
frameworks and deepen the core principles of country ownership, alignment and accountability for
results.
e) Development agencies should provide timely and disaggregated information on their assistance to enable
the government to record foreign aid in the domestic budget, foster its alignment with national priorities,
and give the government a chance to address the coordination challenge.

Government (Executive):
f) Government must provide reliable shreds of evidence that will better inform and educate donors on how
foreign aid can best reduce poverty.
g) Government needs to strengthen the operations of the Service Level Agreement (SLA) unit in the MOHS
especially in terms of expanding the scope of their operations to strengthen monitoring and supervision
of the implementation of donor funds. Specifically, for the unit to collate vital information from donors
on local partners they are working with, the size of the budgets of those local partners, implementation
arrangement including target beneficiaries. A straightforward way of getting such information is for the
local partners to submit their work plans to the SLA unit through the bilateral and NGOs funding the
local partners.
h) Encourage the SLA unit of MOHS to work closely with the DACO of MoPED in terms of information
sharing and joint coordination for the monitoring of the implementation of off-budget donor-funded
projects.
i) DACO to be given the platform to source primary data from the SLA unit of MOHS on the status of
donor-funded projects in the health sector implemented nationwide
j) Ensure leadership is provided to not only coordinate development aid but also ensure donors use already
available framework for reporting and accountability

Parliament:
k) Legislative oversight on aid financing across Ministries, Departments and Agencies must be heightened
to better understand which projects are being implemented and how it contributes to deepening service
delivery for the people.
l) To summon the Executive to account ho how aid is utilised and accompanying impacts on the ordinary
citizens.

3|Page
 The Health Accountability Project

Civil Society and Media:

m) monitoring and tracking the progress of implementation of donor projects and provide the much-needed
feedback to the wider citizenry for informed dialogues and engagement
n) lead advocacy processes including policy dialogues, legislative engagements, as well as utilising the media
to spotlight the significant issues needing concrete actions to promote mutual accountability
o) Facilitate
PARENT TEACHERS dialogue between development partners, Parliament and the Executive on aid accountability
for effective service delivery
ASSOCIATION 20XX
CONCLUSIONS
It is worth noting that there is a limit to what donor aid can achieve. Also, aid effectiveness contributes
immensely to strengthening domestic accountability. Also bear in mind that domestic accountability systems
are complex, dynamic and driven by internal historical, political, social and economic factors. However, the
preceding analysis also shows that some forms of donor aid can make a difference to ensure that they 'do no
harm to existing domestic accountability systems and potentially strengthen these systems. Moreover,
analysing the actors, mechanisms, and information flows around different aid modalities in health has created
a platform better to explore the relationship between aid effectiveness and accountability.

However, gaining a better understanding of how institutions change over time and their contribution to
development results is vital to move away from a narrow focus on short-term impact. Other measures aimed
at fixing incentives within donor agencies and promoting bottom-up planning and country-based dialogues
have the potential to shift the dimensions of aid accountability in the right direction.

Implemented by: With Funds from:

4|Page