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

Abstract

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. April 2010, Sierra 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 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. 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 and drugs free of charge. [ILLUSTRATION OMITTED] 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 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 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 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. …