Bulletin of the World Health Organization

Now it’s free, how to pay for it? Sierra Leone’s dilemma

Free health care for mothers and babies is already saving lives but this war-ravaged country faces many challenges in sustaining such a grand plan. Felicity Thompson reports.

Zainab Camara cradles her two-week-old baby in the postnatal ward of Freetown’s Princess Christian Maternity Hospital. This is the first child she has delivered in a hospital. And lucky that she did. Shortly after giving birth at a regional hospital in Waterloo town, about 30 kilometres outside the capital, Camara began to bleed uncontrollably. She was swiftly transferred to Freetown, where doctors operated to control the bleeding and save her life.

In April 2010, Sierra Leone launched its first free health-care initiative aimed at improving abysmal maternal and child mortality rates (one in eight women risk dying from the complications of childbirth and one in 12 children die before their first birthday). Had Camara given birth before free health care was offered, she says, she would never have come to hospital. Camara brings home the equivalent of about US$ 2 a day from the sale of dried fish at Waterloo’s bustling roadside market. After food and school fees, there is little left for doctor’s visits. Her traditional birth attendant accepted payment in soap bars to help deliver Camara’s first two children at home.

Zainab Camara says she would have had “serious problems” if she had not given birth in hospital.
WHO/Felicity Thompson
Zainab Camara says she would have had “serious problems” if she had not given birth in hospital.

“What made me come in to give birth this time was that I didn’t have to pay anything,” she says. Inspired by similar efforts in Rwanda and Uganda, this initiative offers free health services to all pregnant women, lactating mothers and children aged less than five in Sierra Leone. Government hospitals now offer consultations, treatment, beds, obstetric care and drugs free of charge.

This is no small feat in a country with only around 80 doctors and 40 government hospitals serving a population of 5.5 million (the World Health Organization recommends 20 physicians per 100 000 people). “It’s the biggest operation of its kind in Sierra Leone,” says Dr Samuel Kargbo, director of the reproductive and child health programme at the Ministry of Health and Sanitation. “In the past 20 years, two things have touched the lives of all Sierra Leoneans – one was the end of the war, and the second is free health care.”

Launching free health care for new mothers and their children was an enormous task that involved purging a bloated payroll of ghost workers and raising salaries of trained health workers, the procurement, transportation and storage of US$ 7 million worth of drugs, upgrading monitoring and evaluation systems and producing a basic package of essential health services. Six months in, the hard work is paying off. The Ministry of Health and Sanitation’s first monitoring bulletin on the initiative shows steady positive trends in access of services by women and children, even after adjusting for the spike in numbers due to initial euphoria and curiosity about the initiative. Though too early to measure changes in mortality rates, the sustained increase in women and children getting treatment, and getting it early, suggests that the free services may – as in Camara’s case – be saving lives.

Children receiving artemisinin-based combination therapy for malaria within 24 hours of fever shot up by 372% in May, after the launch. The number of women giving birth in hospital more than doubled in the same month and has since continued to rise. Births attended by trained midwives are also on the increase.

But providing such life-saving services is costly. Maintaining free health care at the point of service will depend on the government’s ability to finance two critical elements: essential drugs and health workers’ salaries.

The Ministry of Health estimates that the free health-care initiative will cost the government an extra US$ 34 million on top of its usual health expenditure in its first year. Despite mineral riches, Sierra Leone remains one of the poorest countries in the world, still recovering from decades of corruption and a long civil war. The government recently raised health spending from 7.8% to 9% of its national budget, bringing this closer to the 15%-by-2015 target agreed by African heads of state in Abuja, Nigeria, in 2001.

A baby is coddled by his mother in the postnatal ward of Freetown's Princess Christian Maternity Hospital.
WHO/Felicity Thompson
A baby is coddled by his mother in the postnatal ward of Freetown's Princess Christian Maternity Hospital.

But the government is far from covering the cost of the free health-care initiative on its own. Donors, including the United Kingdom’s Department for International Development (DfID), The World Bank, the African Development Bank and the Global Fund to Fight AIDS, Tuberculosis and Malaria, will pick up more than half the tab for the first year of the initiative (i.e. until March 2011). At the time of going to press, the total cost to donors was unknown.

A recent World Bank report predicts it will cost an additional US$ 15–25 million per year for the next five years. The report, which considers three scenarios, says even the most optimistic scenario will still not see additional costs met until three or four years into the initiative. In the most conservative scenario, there is no year in the five-year period in which costs even come close to being covered. The scenarios assume that donor aid will increase by between 5% and 50% over current commitments and that the government will raise its health expenditure to 15% of its budget.

If current trends are projected, it is unlikely these costs will be met. The global recession, changes in domestic politics and aid strategies in donor countries are threatening funds needed for the initiative. One of its largest contributors, DfID is now undergoing a bilateral aid review that will determine its future commitments globally.

Susan Mshana, human development team leader and health adviser at DfID’s Sierra Leone office, says DfID will continue to support the free health-care initiative by contributing to health worker salaries over the next five years. “We have committed to providing for salaries on a sliding scale – as they go down, hopefully the government [contribution] will go up. That’s the intention.” DfID will also provide technical assistance over the next three years to build capacity in financial management and human resource planning in the health sector.

Stressing the “long-term financial requirements” of free health care, the World Bank report says extra effort will be required to plug financial gaps in the first three years. Because the initiative depends upon maintaining the salaries of an increasing number of health workers and regular supply of essential drugs, it requires a permanent increase in health costs. With relatively low public health spending, Sierra Leone must rely on other sources, but depending on external aid can be a risky business.

The foundations are being laid for a national health insurance scheme – the only health insurance currently available to Sierra Leoneans is for the few working in the private sector. But analysts agree that a new scheme will not be a reality for several years.

In the meantime, Sierra Leone must find ways to fill the funding gap. President Ernest Bai Koroma has long made clear his intention to wean the country off donor aid. One possibility is to galvanize revenue from its rich natural resources to help fund social service provision. But there are no concrete plans for this yet.

Stuart Zimble, head of Médecins Sans Frontières in Sierra Leone, says the challenge now is to maintain donor interest. Zimble says he already feels “tremors” that big donors may lose interest within a few years if the government cannot provide reliable data showing the system is working to reduce mortality in an efficient way.

Donors say they remain committed to building up Sierra Leone’s health sector. DfID is providing US$ 40 million for a reproductive and child health programme that will run until 2012. The World Bank has committed funding over the next three years and will join DfID in donating one million bednets each to the government’s effort to achieve full coverage. The Global Fund has also provided US$ 45 million to strengthen health systems.

While these projects are essential to building up the overall health sector, they do not cover the additional cost of keeping health care for women and children free. Zimble fears the worst if donors do not step in.

“If the donor funding falls out too quickly, we will see a train wreck,” says Zimble. “And it will be hard for the smaller agencies to pick up the pieces.”

Back at the Princess Christian Maternity Hospital, Sister Mabel Conteh clocks in for her eight-hour shift. She’s been working here as a midwife for 27 years. She now pockets about US$ 240 a month, almost three times her old wage.

“We are much busier these days. I don’t sit down. I’m always with patients. The work is more loaded on us now. But this is our job,” she says.

In a bed nearby, Zainab Camara hugs her baby boy. “I would have had serious problems if I hadn’t [given birth in] hospital this time,” she says.