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One year on: the impact of removing health care user fees in Sierra Leone

A hospital prepares to make healthcare free for mothers and children. Credit: OxfamWhile there are still some commentators who seem stuck on the  question of whether removing fees for health care in poor countries is a good idea at all – thankfully there are others who have moved on to the much more critical question of not whether this should happen – but how.

The recent World Health Report on Health Financing for Universal Coverage leaves no doubt that user fees are a bad idea. In the Director General’s own words, they constitute “by far the greatest obstacle to progress” on the path to universal access.

Learning how to successfully remove fees is best done by looking at those countries that have made that bold step forward. The introduction of free care for pregnant women and children in 2010 in Sierra Leone – a post-conflict nation with a crumbling and severely under-resourced health system and one of the highest rates of maternal deaths in the world – provides very relevant lessons for the numerous other low-income countries facing similar challenges.

Let’s look at the impact first. Before free care for pregnant women and children was introduced in Sierra Leone, 88% of citizens said that their inability to pay was by far the greatest barrier to accessing care when sick.[1]   Just 12 months after the introduction of free care, medical care for children under five has increased by 214% and the proportion of children getting approved treatment for diagnosed malaria increased from 51% to 90%. For pregnant women, deliveries in formal clinics and hospitals increased by 45% and uptake of modern family planning methods went up 140%. More importantly, the number of delivery complications treated in health units increased 150% and the fatality rate in these cases fell by 61%.[2]  This shows us clearly that more women in need of emergency obstetric care are accessing it earlier and that this is making a difference. These positive results recently made it on to the front page of the New York Times.

How did this remarkable change happen? Donnelly’s recent article in The Lancet highlights the key factors. No rocket science here: a high level of political commitment and leadership from the President of Sierra Leone and key staff within the Ministry of Health; health worker reform including the elimination of 850 ghost workers from the payroll; salary increases of at least 100% for all staff; over 1000 additional workers hired; upgrading of a number of facilities to provide a fuller range and better quality of services, and; a desperately needed injection of resources and effort into sorting out the key issue of medicines supply.

Of course there remain big challenges. Of concern is a recent drop off in vaccination coverage likely caused by a breakdown in the medicine cold-chain systems and a potential reduction in primary health care outreach activities. Health worker numbers are still way short of what’s needed; there are concerns in some areas that pregnant women are still paying for services; and there is insufficient infrastructure to build an effective referral system across the country.

But do these challenges mean that free care should not have been introduced? The impact figures cited above challenge anyone who argues that. They suggest that efforts must in fact be redoubled to address long-standing problems that have naturally been exacerbated by a very welcome increase in demand. We need to focus on creating a virtuous rather than vicious circle.

Many commentators suggest conditions must be perfect before fee removal can be considered. In the vast majority of countries this would mean an indefinite wait that put very simply – costs lives.

Instead, the Sierra Leone experience along with others shows that the free care policy itself can be instrumental in bringing needed political attention to long failing elements of the health system, like workers and medicines. Government monitoring of access and quality of services, while still falling far short of what is needed, also seems to have improved relative to before.

The free care policy also achieved something that must be the envy of many other low-income countries – donor co-ordination. Government leadership and determination on this policy forced many of the donors into action, sometimes against their will. Reports from Sierra Leone on the preparation period also confirm that the World Bank supported the introduction of free health care and was a partner to the government in the preparations.[3]

Countries that want to implement free health care shouldn’t have to wait for donors to get their house in order. Rather they should take courage from the example of Sierra Leone and kick start progressive policies in the interests of their citizens which donors should be forced to follow.

[1] Government of Sierra Leone, Ministry of Health and Sanitation (2011) ‘Health Information Bulletin’ Volume 2, Number 3.
[2] Ibid.
[3] Information provided by correspondence with Save the Children UK and to be included in a forthcoming report

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One Response to “One year on: the impact of removing health care user fees in Sierra Leone”

  1. Hi Anna this is a very interesting initiative and the case of Sierra Leone is key for free health care advocates to prouve it can work.

    One suggestion : do you have any concrete information on how this policy in SL was and is still financed? What is the % of donors financial support, what is the % of gvt investment, other sources etc. This will be very useful to show also the financing part of it as a lot a non supporter of a free health care policy are arguing that it is too expensive and LIC can’t afford it.

    Anna: Hi there Annick and thanks for this important question. Part of the answer is provided in an article in the WHO bulletin . The Sierra Leone Ministry of Health estimated that the free care policy would cost an additional US$34 million on top of normal government expenditure for the first year. For the years beyond this the World Bank has estimated the cost as $15 to $20 million per year. The government has raised its own spending from 7.8% to 9% of total government spending. Clearly it could raise a great deal more by meeting the Abuja commitment to spend 15%. Some donors have also stepped up with the UK’s DFID providing a large chunk ($8 million for drugs and supplies over the first and $16 million over the next 5 years). There does remain a financing gap and it would be good to hear from other development partners who are helping to fill this. What is clear is that Sierra Leone is still one of the poorest countries in the world and while the government is keen to reduce the dependence on aid this is simply not a goal that can be achieved in the near future. Therefore sustainability depends on donor agencies living up to their commitments. Not too much to ask when so many lives can be saved as a result. Below is a quote from an interview with Dr. Samuel Kargbo, director of reproductive and child health and Dr. Kisito Daoh, chief medical officer for Sierra Leone on this subject:

    Sustainability is a challenge. For now, and the very near future, the project would still require that we still get support from partners. Maybe in the future, we would have a revenue based model to support this, but I think it in the immediate future we would still be needing support from partners. But again there is the belief that we all got into this venture together, and because of the very laudable goal that we have, and I’m not sure that the partners will let us down.

    Finally, just came across this interesting announcement of a new partnership between DFID, UNICEF and the Sierra Leone government to improve accountability of the medicines for the free health care.

  2. We quote Sam Ukuonzi , Ugandan MP

    “I have perused the reports from Amnesty and Oxfam on free care in Sierra Leone. Basically they both acknowledge key achievements of the FHCI but highlight major challenges. Amnesty gets rather too dramatic on the old problems that existed even before the initiative. The two reports however concur on free-health care being the right thing to do, although more resources are required and major challenges need to be addressed. In my view, significant progress has been made in Sierra Leone – acknowledged by both reports. And this is what matters.

    Sam Okuonzi, member of parliament in Uganda, formerly Head of Health Policy at the MoH, and a university lecturer of health economics and policy.

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Global Health Check is edited by Anna Marriott, Health Policy Advisor for Oxfam GB, and welcomes contributions from different authors. If you would like to write an article for this site or if you have any queries please contact: amarriott@oxfam.org.uk.