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

19 mars 2019Wathinotes systèmes de santé

Author(s): Bulletin of the World Health Organization

Date of Publication: December 2010

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).

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.

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.

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.

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.

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