Policy coherence for resilient health systems: Do Sierra Leone’s health sector strategies active in the 2025 to 2026 planning window pull in the same direction?

Abstract

Sierra Leone is entering a dense period of health sector strategising, with multiple frameworks active across system strengthening, partner coordination, digital transformation, health security, and water, sanitation and hygiene (WASH). Their coexistence raises a critical question: do they reinforce a coherent agenda for resilient, equitable universal health coverage (UHC) or generate fragmentation and implementation burden? We conducted a qualitative health policy analysis combining documentary review of five national strategies, the National Health Sector Strategic Plan (NHSSP) 2026 to 2030, the National Health Compact 2025, the Digital Health Roadmap 2024 to 2026, the National Action Plan for Health Security 2025 to 2029, and the WASH Sector Strategic Plan 2026 to 2035, together with selected Ministry of Health frameworks, and sixteen semi structured key informant interviews. Data were analysed using the Framework Method, guided conceptually by a policy coherence lens spanning strategic priorities, governance, monitoring, financing, and district level implications. The strategies converged around primary health care, equity, service readiness, surveillance, workforce strengthening, WASH, and improved data systems. Coherence was strongest at the level of aspiration and weakest in operational architecture, with three recurrent fault lines: parallel governance structures, fragmented monitoring frameworks, and limited translation of cross cutting ambition into integrated district implementation. Documentary analysis showed misaligned planning horizons, including a Digital Health Roadmap that expires within the first year of the umbrella NHSSP, and indicator sets that define shared priorities differently across documents. Sierra Leone’s policy portfolio is directionally aligned but operationally fragmented. Strengthening coherence will require a clearer strategy hierarchy, a unified results framework, rationalised coordination, embedded digital governance, stronger health, WASH and health security integration, and financing that supports cross programme implementation. Findings derive from a purposive sample and are analytical rather than statistically representative.