Published on Africa Can End Poverty

If it is free, people will queue up…but for how long?

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It’s a long ride on a non-motorable road to Pujehun district in the south of Sierra Leone.  We are on a visit to see how the country’s Free Health Care Initiative (FHCI) for pregnant women and young children is working out. 

In the maternity ward of the district hospital, a woman proudly shows us her new born baby – it’s her third child and fourth pregnancy.  But, more importantly, her first child to be delivered in a hospital.  She is among the thousands of women who have delivered in hospitals for the first time since the introduction of free health care. Are we seeing early signs of a change in health seeking behavior among the poor in the country?

The rationale for FHCI looks compelling – the high costs of health care have prevented most Sierra Leoneans from accessing institutional health care facilities.  Some reports have placed out of pocket spending for health in Sierra Leone amongst the highest in Africa.  While the exact spending may be debatable, most people agree that financial costs have been a principal barrier.  The resulting mortality rates have been appalling. 

This has been the story for decades, as successive governments and donors poured money into the health sector with little tangible improvements in the country’s human development indicators.

When free health care was introduced in April 2010, many commentators raised concerns about inadequate preparation and the risks of subjecting the system to a ‘shock’.  So the recent Amnesty International report should not come as a surprise – it argues that despite its successes, the free health care initiative has been suffering from inadequate drugs, corruption, weak capacity and little accountability.  This is a familiar story in the world of development.


At the same time many believe that some of the building blocks for a successful war against high maternal and infant mortality rates are present in Sierra Leone: commitment at the highest level in government; adequate funding, at least in the short-term; and some level of momentum in the public health care system (as opposed to decades of inertia).  This can certainly sustain it for some time, but before long one could see the queues outside the clinics disappearing.  Government data indicate that after the huge spurt in clinic attendance in the initial months of FHCI, since early 2011 there has been a steady decline.

Going forward, government and its partners should focus on three important things:

Sustainability: some estimates show that in the first year public spending for the initiative has been about 2.8% of GDP – roughly a doubling the share before FHCI.  In the short-term this has been financed principally through increases in donor and government funding.  But how can this be financed over the medium-term?  Various estimates show that the country’s domestic revenues could grow dramatically in a short period of time on the back of developments in the extractives sector.  If that happens, then what is needed is political commitment in order to ensure that adequate budgetary allocations are made for key health priorities.

Ensuring quality: At the time of introducing FHCI, there was a big increase in salaries of health workers.  It should come as no surprise that this has not been sufficient in improving quality services.  There is a need for building in greater incentives into the system for improving quality, and the work now commencing on Results Based Financing could be important.  Additionally, there is a need to clarify the existing division of responsibilities among different players – Sierra Leone has a system of decentralized delivery of basic services.The central government should not end up doing the work of local councils.

Stronger accountability:  finally, what would it take for the woman we met in the Pujehum hospital to advise her friends to go to a hospital for delivery?  She needs to have the assurance that her voice will be heard, that she has an avenue to provide feedback, and the feedback is being acted upon.  Like women anywhere in the world, a pregnant woman in Sierra Leone does not want to die.  So make her the center of the initiative.  This is perhaps the best way to strengthen accountability in the system, but an area which has gotten scant attention during the implementation of the free health care initiative.  Again, some of the pieces are starting to fall into place, with new Bank-supported initiatives on use of ICT and social accountability systems.

It is time for some mid-course corrections for Sierra Leone’s free health care initiative to deliver what it says on the can…


Vijay Pillai

World Bank Country Manager for Sierra Leone

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