Free Health Care Initiative Research Articles

Infant Mortality and Desired Fertility: The Case of the Free Health Care Initiative in Sierra Leone

Sierra Leone launched the Free Health Care Initiative, which abolished health user fees for pregnant and breastfeeding women and children under five years of age, in 2010. Combining data from the Demographic and Health Survey and a geocoded dataset for the distribution of public health facilities, I design a difference-in-differences study involving birth timing and transportation cost to investigate its impact on infant mortality and desired fertility. I find that the program does not achieve its goal of reducing infant mortality, with the lack of vaccination being a major problem. Notwithstanding the lack of reduction in infant mortality, the program leads to a significant decline in desired fertility, implying that parents may overestimate the program’s benefits and change their expectations of infant mortality accordingly. Heterogeneous effects by household wealth suggest that poor households are more adversely affected by the program than wealthy ones.

Coordination of health and rehabilitation services for person with disabilities in Sierra Leone – a stakeholders’ perspective

Purpose To explore stakeholders’ perceptions of the coordination of health and rehabilitation services for persons with disabilities in Sierra Leone. Materials and methods A qualitative study including seven focus group discussions with health, rehabilitation, and disability organisations stakeholders in Sierra Leone. Content analysis was used for data analysis. Results One theme emerged; poor governance in implementing disability policies, healthcare, and rehabilitation services, which included seven subthemes: insufficient implementation of healthcare policies for persons with disabilities; changes, lack of coordination and communication between ministries governing disability policies and rehabilitation services; need for accurate disability data and clinical record keeping; absence of funds and poor political priority to healthcare and rehabilitation services; continuous support for non-governmental organisations (NGOs) to provide healthcare and rehabilitation service delivery; lack of coordination between different healthcare and rehabilitation service providers and calling for increasing persons with disabilities capacity for greater inclusion in society. Conclusions Increasing governmental prioritisation, and ensuring coordination and trust between donors, NGOs, and governmental programmes were keys for sustainable health and rehabilitation services. Stakeholders need to ensure national coverage and equally distributed health and rehabilitation services. Including rehabilitation services and assistive technology in the Free Healthcare Initiative would contribute to implementing the Disability Act. Implications for rehabilitation Political prioritisation of persons with disability (PWD) need to increase to provide national coverage and equally distributed health and rehabilitation services for PWD. To ensure access to rehabilitation services and access to basic assistive technology for PWD, the government of Sierra Leone could agree on basic rehabilitation services and a priority list of assistive devices to be distributed through rehabilitation centres and funded by the Free Health Care Initiative programme or the Sierra Leone health insurance scheme. To increase access to health services for PWD, the government of Sierra Leone could ensure inclusion of PWD in the Free Health Care Initiative programme. The government, donors, and organisations providing or funding health and rehabilitation services for PWD need to mobilise and coordinate resources better and be mutually held accountable to maximise the benefits of PWD resources.

“Where my pocket can afford is where I will take my child”. The influence of structural factors on the health-seeking behaviour of the population in Gorama Mende and Wandor chiefdoms, Kenema district, Sierra Leone

In Sierra Leone, maternal and under-five mortality rates are among the highest in the world. In 2010, the government adopted the Free Healthcare Initiative (FHCI) providing free healthcare for children aged under-five and pregnant and lactating women. However, the FHCI is seriously impeded by the limited availability of health staff, gaps in medication supply, and weak management. In this paper, we present experiences of the Gorama Mende and Wandor (GMW) chiefdom residents in Kenema district, Sierra Leone and how they navigate available options to seek care. We argue that the health-seeking behaviour (HSB) of the population is influenced by interrelated structural and social factors. This qualitative research was conducted in rural GMW chiefdoms in February 2020, using in-depth individual, paired, and group interviews. Contrary to the assumption that traditional healers influence HSB, data suggest that structural factors like proximity, affordability, previous experience, and reception at the health facility were the main determinants. Healthcare providers felt that people went to a traditional healer first; however, the population emphasised that their first choice was always the peripheral health unit (PHU) provided there were no barriers. These barriers include, living in hard-to-reach areas, transportation, unexpected payment for services, and fear of the health staff. The study reveals the complex reality people face in terms of access to healthcare and multiple factors that influence HSB. One community member noted that if people could not afford a PHU, they would turn to alternative forms of healthcare — ‘Where my pocket can afford is where I will take my child’.

What are the trends in seeking health care for fever in children under-five in Sierra Leone? evidence from four population-based studies before and after the free health care initiative.

BackgroundIn 2010, the government of Sierra Leone implemented the Free Health Care Initiative (FHCI) in the country with the objective of reducing the high maternal, infant, and child mortality rates and improving general health indicators. The objective of this study was to assess the trends in the prevalence of health care-seeking and to identify the determinants of healthcare service utilization by caregivers of children younger than five years.MethodsThe analysis of health-care-seeking behavior was done using data from four population-based surveys in Sierra Leone before (2008) and after (2013, 2016, 2019) the FHCI was implemented. Care-seeking behavior was assessed with regard to caregivers seeking care for children under-five in the two weeks prior to each survey. We compared the percentages of healthcare-seeking behavior change and identify factors associated with healthcare-seeking using a modified Poisson regression model with generalized estimating equations.ResultsIn 2008, a total of 1208 children with fever were recorded, compared with 2823 children in 2013, 1633 in 2016, and 1464 in 2019. Care-seeking for children with fever was lowest in 2008 (51%; 95% CI (46.4−55.5)) than in 2013 (71.5%; 95% CI (68.4−74.5)), 2016 (70.3%; 95% CI (66.6−73.8)), and 2019 (74.6%; 95% CI (71.6−77.3)) (p < 0.001). Care-seeking in 2013, 2016 and 2019 was at least 1.4 time higher than in 2008 (p < 0.001) after adjusting for mother’s age, wealth, religion, education level, household head and the child’s age. Care-seeking was lowest for children older than 12 months, mothers older than 35 years, children living in the poorest households, and in the northern region. A trend was observed for the sex of the household head. The level of care-seeking was lowest when the household head was a man.ConclusionsThe increase in healthcare-seeking for children under-five with fever followed the introduction of the FHCI in Sierra Leone. Care-seeking for fever varied by the child’s age, caregiver’s age, household wealth, the sex of the household head and region. Maintaining the FHCI with adequate strategies to address other barriers beyond financial ones is essential to reduce disparities between age groups, regions and, households.

Barriers to increase surgical productivity in Sierra Leone: a qualitative study

ObjectiveTo explore factors influencing surgical provider productivity and identify barriers against and opportunities to increase individual surgical productivity in Sierra Leone, in order to explain the observed increase in unmet...

Catastrophic expenditure and impoverishment after caesarean section in Sierra Leone: An evaluation of the free health care initiative.

BackgroundUtilizing surgical services, including caesarean sections, can result in catastrophic expenditure and impoverishment. In 2010, Sierra Leone introduced the Free Health Care Initiative (FHCI), a national financial risk protection program for the most vulnerable groups. Aim of this study was to investigate catastrophic expenditure and impoverishment related to caesarean section in Sierra Leone and evaluate the impact of the FHCI.MethodsWomen who delivered by caesarean section in nine hospitals were followed up with home visits one month after surgery, and data on medical and non-medical expenditures were collected. Individual income was estimated based on household characteristics and used to determine catastrophic expenditure and impoverishment for each patient. The impact of the FHCI was assessed by comparing actual expenditure with counterfactual expenditures had the initiative not existed.ResultsFor the 1146 patients in the study, the median expenditure was 23 (IQR 4; 56) international dollars (Int$). Patients in the poorest quintile spent a median Int$ 59 (IQR 28; 76), which was significantly more than patients in the richest quintile, who spent a median Int$ 17 (IQR 2; 38, p<0.001). Travel (32.9%) and food (28.7%) were the two largest expenses. Catastrophic expenditure was encountered by 12.0% and 4.0% (10% and 25% threshold, respectively) of the women. Without the FHCI, 66.1% and 28.8% of the women would have encountered catastrophic expenditure.ConclusionMany women in Sierra Leone face catastrophic expenditure related to caesarean section, mainly through food and travel expenses, and the poor are disproportionally affected. The FHCI is effective in reducing the risk of catastrophic expenditure related to caesarean section, but many patients are still exposed to financial hardship, suggesting that additional support is needed for Sierra Leone’s poorest patients.

Improving Access to Healthcare in Sierra Leone: The Role of the Newly Developed National Emergency Medical Service.

We aim to evaluate whether the first National Emergency Medical Service (NEMS) improved access to hospital care for the people of Sierra Leone. We performed an interrupted time-series analysis to assess the effects of NEMS implementation on hospital admissions in 25 facilities. The analysis was also replicated separately for the area of Freetown and the rest of the country. The study population was stratified by the main Free Health Care Initiative (FHCI) categories of pregnant women, children under 5 years of age, and populations excluded from the FHCI. Finally, we calculated direct costs of the service. We report a 43% overall increase in hospital admissions immediately after NEMS inception (RR 1.43; 95% CI 1.2–1.61). Analyses stratified by FHCI categories showed a significant increase among pregnant women (RR 1.54; 95% CI 1.33–1.77) and among individuals excluded from the FHCI (RR 2.95; 95% CI 2.47–3.53). The observed effect was mainly due to the impact of NEMS on the rural districts. The estimated recurrent cost per ambulance ride and NEMS yearly cost per inhabitant were 124 and 0.45 USD, respectively. To our knowledge, this is the first nationwide study documenting the increase in access to healthcare services following the implementation of an ambulance-based medical service in a low-income country. Based on our results, NEMS was able to overcome the existing barriers of geographical accessibility and transport availability, especially in the rural areas of Sierra Leone.

Socioeconomic inequalities in curative healthcare-seeking for children under five before and after the free healthcare initiative in Sierra Leone: analysis of population-based survey data

BackgroundSocioeconomic inequalities between and within countries lead to disparities in the use of health services. These disparities could lead to child mortality in children under 5 years by depriving them of healthcare. Therefore, initiatives to remove healthcare fees such as the Free Healthcare Initiative (FHCI) adopted in Sierra Leone can contribute to reducing these inequities in healthcare-seeking for children. This study aimed to assess the socioeconomic inequalities in healthcare-seeking for children under 5 years of age before and after the implementation of the FHCI.MethodsData were included on 1207, 2815, 1633, and 1476 children under 5 years of age with fever from the 2008, 2013, 2016, and 2019 nationwide surveys, respectively. Concentration curves were drawn for the period before (2008) and after (2013–2019) the implementation of the FHCI to assess socioeconomic inequalities in healthcare-seeking. Finally, Erreyger’s corrected concentration indices were calculated to understand the magnitude of these inequalities.ResultsBefore the implementation of the FHCI, there were inequalities in healthcare-seeking for children under five (Erreyger’s corrected concentration index (CI) = 0.168, standard error (SE) = 0.049; p < 0.001) in favor of the wealthy households. These inequalities decreased after the implementation of the FHCI (CI = 0.061, SE = 0.033; p = 0.06 in 2013, CI = 0.039, SE = 0.04; p = 0.32 in 2016, and CI = − 0.0005, SE = 0.362; p = 0.98 in 2019). Furthermore, before the implementation of the FHCI, a significant pro-rich inequality in the districts of Kenema (CI = 0.117, SE = 0.168, p = 0.021), Kono (CI = 0.175, SE = 0.078, p = 0.028) and Western Area Urban (CI = 0.070, SE = 0.032, p = 0.031) has been observed. After the implementation of the FHCI in 2019, these disparities were reduced, 11 of the 14 districts had a CI around the value of equality, and only in 2 districts the pro-rich inequality were significant (Western Area Urban (CI = 0.035, SE = 0.016, p = 0.039) and Western Area Rural (CI = 0.066, SE = 0.030, p = 0.027)).ConclusionThe results of this study demonstrated that socio-economic inequalities in healthcare-seeking for children have been considerably reduced after the FHCI in Sierra Leone. To further reduce these inequalities, policy actions can focus on the increase of availability of health services in the districts where the healthcare-seeking remained pro-rich.

Care-Seeking for Fever for Children Under the Age of Five Before and After the Free Healthcare Initiative in Burkina Faso: Evidence from Three Population-Based Surveys.

BackgroundIn 2016, a free healthcare policy (FHP) was implemented in Burkina Faso for children under the age of five. In our study, we aimed to determine the prevalence of care-seeking for a fever in children under the age of five before and after the implementation of the FHP and to analyze the determinants of not seeking care under the FHP.MethodsThe data of three nationally representative surveys were used to evaluate the trends of the prevalence of care-seeking. We performed a modified Poisson regression using a generalized estimating equation to determine the factors associated with not seeking care.ResultsThe prevalence for care seeking increased from 57.5% (95% CI, 54.2–60.8) in 2014 to 72.3% (95% CI, 68.1–76.2) in 2017. Children from the poor quintile were less likely to seek care when compared to children from the poorest quintile (prevalence ratio (PR) = 0.7 (95% CI, 0.5–0.9)). Caregivers who did not have messages regarding malaria in the past six months were more likely not to seek care (PR = 0.8 (95% CI, 0.7–0.9)). Caregivers of children aged 36–59 months were more likely not to seek care compared to those aged <12 months (PR = 1.6 (95% CI, 1.2–2.1)). Children from the Boucle du Mouhoun region (PR = 1.9 (95% CI, 1.2–3.2)) and the Centre-Est region (PR = 1.9 (95% CI, 1.2–3.0)) were more likely not to seek care compared to children from the Sud Ouest region.ConclusionOur study showed an increase in the prevalence of care-seeking after the implementation of the FHP. Even if this is encouraging, these findings highlight the critical importance of non-financial barriers to care-seeking. Maintaining FHP and tackling the barriers should be considered by policy makers to increase care-seeking.

Ebola survivors’ healthcare-seeking experiences and preferences of conventional, complementary and traditional medicine use: A qualitative exploratory study in Sierra Leone

Backgroundand Purpose: This study explores Ebola survivors' healthcare-seeking experiences within the context of Sierra Leone's free healthcare initiative (FHCI) and comprehensive package for Ebola survivors (CPES) program while also exploring the enablers and barriers to their use of informal healthcare. Materials and methodsWe employed an inductive, exploratory qualitative approach using focus group discussion with 41 adults Ebola survivors in the four administrative regions of Sierra Leone. ResultsBiomedical care was the first choice of treatment option for most survivors immediately following post-ETC discharge. Survivors' healthcare-seeking experience varies before and after their inclusion into FHCI and the establishment of the CPES program. Personal and health system factors influenced survivors’ decision to seek multiple healthcare approaches, especially T&CM. ConclusionOur findings suggest the determinants of Ebola survivors’ healthcare-seeking experiences should be considered when developing and implementing programs aimed at improving the current health status of Ebola survivors in Sierra Leone.

Factors associated with the upsurge in the use of delivery care services in Sierra Leone

ObjectivesMost African countries have poor maternal and reproductive health outcomes. This is due, in part, to many factors such as accessibility issues, which hinder women in developing countries from using life-saving maternal and reproductive health services. Therefore, this study considered two main objectives: (i) to examine prevalence of delivery care services in Sierra Leone; and (ii) to identify sociodemographic factors associated with the use of the aforementioned health services. Study designA secondary analysis was undertaken using data from the Sierra Leone Demographic and Health Surveys. MethodsBivariate and multivariate analyses were used to study the prevalence and factors associated with the use of delivery care services in Sierra Leone. ResultsThe findings show a general increase in the use of delivery care services between 2008 and 2013, although the use of these services remains quite low. The multivariate analysis shows that maternal age, marital status, socio-economic status, the number of living children, decision-making power, media exposure, skilled antenatal care, and geographic location are crucial factors in the use of delivery care services. ConclusionsUse of delivery care services remains low in Sierra Leone. It is possible that the introduction of the Free Healthcare Initiative played a vital role in increasing the use of these services. Further policy debates are needed to ensure universal coverage.

Women’s economic empowerment and health related decision-making in rural Sierra Leone

Maternal mortality rates during childbirth in Sierra Leone are amongst the highest globally, with 1360 maternal deaths per 100,000 live births. Furthermore, the country’s neonatal mortality rate is estimated at 39 deaths per 1000 live births. There is growing recognition of the health consequences of gender inequality, but challenges in addressing it. Gendered power dynamics within households affect health outcomes, with men often controlling decisions about their family’s health, including their family’s use of health services. The Government’s Free Health Care Initiative, which abolished user fees for pregnant women, lactating mothers and children under five is promising, however this reform alone is insufficient to meet health goals. Using in-depth interviews and focus group discussions with men and women, this study explores women’s economic empowerment and health decision-making in rural Sierra Leone. Findings show the concept of power related to women’s income generation, financial independence and being listened to in social relationships. Whilst women’s economic empowerment was reported to ease marital tensions, men remained household authority figures, including regarding health decision-making. Economic interventions play an important role in supporting women’s economic empowerment and in influencing gender norms, but men’s roles and women’s social empowerment, alongside economic empowerment, needs consideration.

Impact of the free healthcare initiative on wealth-related inequity in the utilization of maternal & child health services in Sierra Leone

BackgroundAs a result of financial barriers to the utilization of Maternal and Child Health (MCH) services, the Government of Sierra Leone launched the Free Health Care Initiative (FHCI) in 2010. This study aimed to examine the impact of the FHCI on wealth related inequity in the utilization of three MCH services.MethodsWe analysed data from 2008 to 2013 Sierra Leone Demographic Health Surveys (SLDHS) using 2008 SLDHS as a baseline. Seven thousand three hundred seventy-four and 16,658 women of reproductive age were interviewed in the 2008 and 2013 SLDHS respectively. We employed a binomial logistic regression to evaluate wealth related inequity in the utilization of institutional delivery. Concentration curves and indices were used to measure the inequity in the utilization of antenatal care (ANC) visits and postnatal care (PNC) reviews. Test of significance was performed for the difference in odds and concentration indexes obtained for the 2008 and 2013 SLDHS.ResultsThere was an overall improvement in the utilization of MCH services following the FHCI with a 30% increase in institutional delivery rate, 24% increment in more than four focused ANC visits and 33% increment in complete PNC reviews. Wealth related inequity in institutional delivery has increased but to the advantage of the rich, highly educated, and urban residents. Results of the inequity statistics demonstrate that PNC reviews were more equally distributed in 2008 than ANC visits, and, in 2013, the poorest respondents ranked by wealth index utilized more PNC reviews than their richest counterparts. For ANC visits, the change in concentration index was from 0.008331[95% CI (0.008188, 0.008474)] in 2008 to − 0.002263 [95% CI (− 0.002322, − 0.002204)] in 2013. The change in concentration index for PNC reviews was from − 0.001732 [95% CI (− 0.001746, − 0.001718)] in 2008 to − 0.001771 [95% CI (− 0.001779, − 0.001763)] in 2013. All changes were significant (p value < 0.001).ConclusionThe FHCI appears to be improving access to and utilization of MCH services, narrowing the inequity in ANC visits and PNC reviews, but is insufficient in addressing wealth- related inequity that exists for institutional deliveries. If Sierra Leone is to realize a significant reduction in maternal and child mortality rates, it needs to strengthen the effective implementation of FHCI considering incorporating a sector wide approach (SWAp) or a “Health in all Policy” framework to reach the less educated, rural residents and ensuring culturally sensitive quality services.

Experiences and preferences of conventional, complementary and traditional medicine use among Ebola survivors in Sierra Leone

and Purpose: This study explores Ebola survivors' healthcare-seeking experiences within the context of Sierra Leone's free healthcare initiative (FHCI) and comprehensive package for Ebola survivors (CPES) program while also exploring the enablers and barriers to their use of informal healthcare.We employed an inductive, exploratory qualitative approach using focus group discussion with 41 adults Ebola survivors in the four administrative regions of Sierra Leone.Biomedical care was the first choice of treatment option for most survivors immediately following post-ETC discharge. Survivors' healthcare-seeking experience varies before and after their inclusion into FHCI and the establishment of the CPES program. Personal and health system factors influenced survivors’ decision to seek multiple healthcare approaches, especially T&CM.Our findings suggest the determinants of Ebola survivors’ healthcare-seeking experiences should be considered when developing and implementing programs aimed at improving the current health status of Ebola survivors in Sierra Leone.

Correction: Distance, accessibility and costs. Decision-making during childbirth in rural Sierra Leone: A qualitative study

[This corrects the article DOI: 10.1371/journal.pone.0188280.].

Distance, accessibility and costs. Decision-making during childbirth in rural Sierra Leone: A qualitative study.

BackgroundSierra Leone has one of the highest maternal mortality ratios in the world. Efforts to reduce maternal mortality have included initiatives to encourage more women to deliver at health facilities. Despite the introduction of the free health care initiative for pregnant women, many women still continue to deliver at home, with few having access to a skilled birth attendant. In addition, inequalities between rural and urban areas in accessing and utilising health facilities persist. Further insight into how and why women make decisions around childbirth will help guide future plans and initiatives in improving maternal health in Sierra Leone. The objective of this study was to explore the perceptions and decision-making processes of women and their communities during childbirth in rural Sierra Leone.Methods and findingsData were collected through seven focus group discussions and 22 in-depth interviews with recently pregnant women and their community members in two rural villages. Data were analysed using systematic text condensation. Findings revealed that decision-making processes during childbirth are dynamic, intricate and need to be understood within the broader social context that they take place. Factors such as distance and lack of transport, perceived negative behaviour of hospital staff, direct and indirect financial obstacles, as well as the position of women in society all interact and influence how and what decisions are made.ConclusionsPregnant women face multiple interacting vulnerabilities that influence their healthcare-seeking decisions during pregnancy and childbirth. Future initiatives to improve access and utilisation of safe healthcare services for pregnant women need to be based on adequate knowledge of structural constraints and health inequities that affect women in rural Sierra Leone.

Strengthening the Free Healthcare Initiative and Hospital-Based Service Delivery in Sierra Leone through a hospital-based Social Worker program

Strengthening the Free Healthcare Initiative and Hospital-Based Service Delivery in Sierra Leone through a hospital-based Social Worker program

Strengthening the Free Healthcare Initiative through a pharmacy and supply chain intervention: Partners in Health's experience in rural Sierra Leone

Abstract Background To improve high maternal and under-5 mortality—among the worst globally—Sierra Leone's Ministry of Health and Sanitation (MOHS) enacted the Free Healthcare Initiative in 2010. Under this initiative, pregnant and lactating women and children aged younger than 5 years receive medical treatment and essential medicines free of charge at public facilities. However, the availability of medicines remains inconsistent, which results in patients paying for medicines and an undermining of the quality of care and trust in the health-care system. These gaps between services and medicines promised under the Free Healthcare Initiative and actual resources delivered worsened during the 2013–15 Ebola epidemic, which strained an already weak health-care system. Here, we describe an approach to strengthen pharmacy and supply chain systems to improve access to essential medicines at a district hospital in Sierra Leone. Methods In 2015, Partners In Health undertook a gap analysis to understand the barriers to drug availability for patients eligible for the Free Healthcare Initiative at Koidu Government Hospital (KGH). A multidisciplinary task force identified priorities and created a partnership with the MOHS. Partners In Health's Director of Pharmacy led meetings with hospital management, shadowed clinical staff, and performed an inventory of drugs and medical supplies. Findings The gap analysis revealed challenges in the areas of human resources, infrastructure, storage, and information systems. The results led to the following interventions: decentralisation of medication distribution from hospital to ward level; the hiring of four pharmacy technicians; expansion of central warehousing; and implementation of electronic reporting tools to improve consumption data. MOHS pharmacy staff were mentored to improve feedback mechanisms between central and district levels. Between November, 2015, and August, 2016, these changes resulted in nearly 100% availability of essential drugs—with 80% provided via the strengthened MOHS system—and elimination of out-of-pocket expenses for patients. Additionally, trust in the public health-care system has improved: compared with a 2012 and 2013 pre-Ebola baseline at KGH, paediatric and maternity admissions have increased by 47%, with a 95% increase in hospital-based deliveries. Interpretation The success of the Free Healthcare Initiative is rooted in its shared ownership with the MOHS and the integration of central-level and district-level information systems. The approach described here could be used to guide new interventions to strengthen pharmacy supply chains elsewhere in Sierra Leone and other low-resource settings. Funding Partners In Health, Sierra Leone.

Can Sierra Leone maintain the equitable delivery of their Free Health Care Initiative? The case for more contextualised interventions: results of a cross-sectional survey.

BackgroundIn 2010, the Ministry of Health and Sanitation in Sierra Leone launched their Free Health Care Initiative (FHCI) for pregnant and lactating mothers and children under-5. Despite an increase in the update of services, the inequitable distribution of health services and health facilities remain important factors underlying the poor performance of health systems to deliver effective services. This study identifies current gaps in service delivery across two rural locations served by the same District Health Management Team (DHMT).MethodsWe employed a cross-sectional household survey using a two-stage probability sampling method to obtain a sample of the population across two rural locations in Bonthe District: the riverine and the mainland. Overall, a total of 393 households across 121 villages were surveyed in the riverine and 397 households across 130 villages were sampled on the mainland. Maternal health, child health and sanitation indicators in Bonthe District were compared using Pearson Chi-Squared test with Yates’ Continuity Correction across the two areas.ResultsWomen across the two regions self-reported significantly different uptake of family planning services. Children on the mainland had significantly greater rates of health facility based deliveries; being born in the presence of a skilled birth attendant; completed immunisation schedules; and higher rates of being brought to the health centre within 24 h of developing a fever or a suspected acute respiratory infection. Households on the mainland also reported significantly greater use of treated water and unrestricted access to a latrine.ConclusionsIf the government of Sierra Leone is going to deliver on their promise to free health care for pregnant women and their children, and do so in a way that reduces inequalities, greater attention must be paid to the existing service delivery gaps within each District. This is particularly relevant to health policy post-Ebola, as it highlights the need for more contextualised service delivery to ensure equitable access for women and children.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1496-1) contains supplementary material, which is available to authorized users.

Free health care for under-fives, expectant and recent mothers? Evaluating the impact of Sierra Leone's free health care initiative.

This study evaluates the impact of Sierra Leone’s 2010 Free Health Care Initiative (FHCI). It uses two nationally representative surveys to identify the impact of the policy on utilisation of maternal care services by pregnant women and recent mothers as well as the impact on curative health care services and out-of-pocket payments for consultation and prescription in children under the age of 5 years. A Regression Discontinuity Design (RDD) is applied in the case of young children and a before-after estimation approach, adjusted for time trends in the case of expectant and recent mothers. Our results suggest that children affected by the FHCI have a lower probability of incurring any health expenditure in public, non-governmental and missionary health facilities. However, a proportion of eligible children are observed to incur some health expenditure in participating facilities with no impact of the policy on the level of out-of-pocket health expenditure. Similarly, no impact is observed with the utilisation of services in these facilities. Utilisation of informal care is observed to be higher among non-eligible children while in expectant and recent mothers, we find substantial but possibly transient increases in the use of key maternal health care services in public facilities following the implementation of the FHCI. The diminishing impact on utilisation mirrors experience in other countries that have implemented free health care initiatives and demonstrates the need for greater domestic and international efforts to ensure that resources are sufficient to meet increasing demand and monitor the long run impact of these policies.