I recently attended a community paralegal training on promoting accountability in health care delivery in Makeni, Sierra Leone. During the training, a community paralegal named Elizabeth Massalay talked about bringing her niece to a clinic in Moyamba district to receive immunizations that the government provides free of charge thanks to the Free Health Care Initiative (FHCI), which offers free health services to pregnant and breastfeeding women and children under five. Mothers queued for free immunizations, painting a hopeful picture for a country that ranks 180 out of 187 in the 2011 Human Development Index and where almost one in three children die before reaching the age of five.
However, against this promising backdrop, Elizabeth saw that the nurse was demanding six cups of rice from each mother before providing the immunization. Elizabeth was witnessing how breakdowns within state institutions—including absent nurses, improper user fees, and “leakage” of up to 30% of FHCI drugs (according to government and UNICEF statistics)—undermine health care delivery. Responding to such breakdowns requires an understanding of health policy and regulations—what the state must provide and to whom—and knowing where and how to apply pressure when the state fails to do so.