Equity Case Study: Sierra Leone - Removing health care user fees to improve prospects for mothers and children
A nurse registers pregnant women, who are queuing for antenatal consultations at the Princess Christian Maternity Hospital in Freetown, the capital.
By Abhijit Shanker
23 November 2011 - The Free Health Care Initiative (FHCI) for children under five years of age, pregnant women and lactating mothers is a signature policy of the Government of Sierra Leone established in April 2010 to further the aims of the country’s Health Sector Strategic Plan and its Poverty Reduction Strategy Paper (PRSP II), dubbed the “Agenda for Change.” The FHCI outlines how prospects for women and children can be positively altered by delivering an essential package of health care services free of charge through public health facilities to ensure a significant improvement in maternal and child health. The initiative strongly supports advocacy efforts by UNICEF and other UN partners to improve maternal and child health in Sierra Leone.
Before introduction of free health care (FHC) in Sierra Leone, 88 per cent of citizens said that their inability to pay was the greatest barrier to accessing care when sick. A year after the inception of FHC, data collected by the health information system reflected a 150 per cent improvement in maternal complications managed at health facilities and a 61 per cent reduction in the maternal case fatality rate in that first year of FHC compared with the previous period. Furthermore, medical care for children under five has increased by 214 per cent, and the case fatality rate for malaria in public hospitals has fallen dramatically by approximately 90 per cent. At the same time, the number of acceptors of modern family planning methods at facilities rose by 140 per cent.
Despite these successes, challenges remain. Of particular concern is the decline in full immunization by 12 months of age after implementation of FHC caused by a breakdown in cold chain systems. A reduction in primary health care activities like outreach due to a heavier workload at health centers could also have contributed to the drop. Other challenges include a shortfall in the number and training of health workers, imposed payments for free services, and insufficiency of the health system infrastructure to support an effective nationwide referral system.
Bringing the FHCI to life was a massive project that required the collaboration of the Ministry of Health and Sanitation (MoHS), local authorities and other government entities, civil society and development partners who all supported its implementation. UNICEF is supporting the Government efforts to strengthen the MoHS procurement and supply chain management system. UNICEF co-chairs the Leadership and Governance and Procurement and Supply Management working groups, two of the seven such groups which review various aspects of implementation. UNICEF staff members also participate as members of the Planning and Budgeting, Monitoring and Evaluation Infrastructure, Health Financing, Human Resources for Health working groups.
In order to ensure sustainability of this initiative, the Government needs the continued support of its partners to ensure that women and children, no matter what their socio-economic circumstances or geographic location, receive high-quality, free health services which will contribute significantly to a reduction in morbidity and mortality and ensure national progress.
For many years Sierra Leone held the unenviable position of last place in the UN Human Development Index because of its alarming health indicators. Maternal and child deaths peaked in 2000 with 1,800 mothers dying for every 100,000 live births and 286 children under five dying for every 1,000 live births, the highest levels globally.
According to the national Demographic and Health Survey 2008, significant improvements in the health status of women and children were realized and maternal mortality had declined to 857 per 100,000 live births and under-five child mortality had fallen to 140 per 1,000 live births. Despite improvements, these figures show that maternal and under-five mortality rates remain unacceptably high, due largely to inadequate health care services and difficulties in access and utilization of services. As a result, Sierra Leone is off track to meet Millennium Development Goals (MDGs) 4 (reducing child mortality) and 5 (improving maternal mortality).
The low utilization of health services is due to a number of factors affecting the entire health system, including charges levied at the point of service delivery; limited access to health services; dilapidated facilities; lack of basic equipment; insufficient medical supplies; demotivated and underpaid staff; and, inadequate financial resources. Low levels of confidence in the quality of health care also negatively affected demand.
In order to tackle the high mortality rates and accelerate efforts toward achieving the health-related MDGs, the Government of Sierra Leone has prioritized maternal and child health improvements. The focus on maternal and child health in the PRSP II (2008-2012) and the launch of the Reproductive and Child Health Strategic Plan in 2008 by the MoHS in collaboration with key partners were important beginnings to address the high rates of maternal and infant mortality.
It is against this background that His Excellency the President of Sierra Leone, Dr. Ernest Bai Koroma announced at the 2009 UN General Assembly that his Government would remove user fees - the most common barrier to health services access - and provide free health care to pregnant women, nursing mothers and children under five years old, beginning on 27 April 2010.
Strategy and Implementation
Research showed that a user fee is the most important factor barring access to health care during times of illness. By removing user fees, the FHCI expected to increase demand for services significantly, particularly by people in hard-to-reach areas, and to achieve desired coverage with essential interventions that could result in improved maternal and child health and eventually a reduction in high mortality rates.
UNICEF has focused its efforts on providing the Government of Sierra Leone with expertise in logistics and supply chain management (procurement, clearing, transportation, warehouse management and supply monitoring); communication and community mobilization; monitoring and evaluation (M&E - printing and distribution of registers and cards, development of indicators); capacity building (training of health workers, logistics management information systems); and infrastructure development (rehabilitation and equipment of three district medical stores, construction of a maternity hospital in one district with a potential service base of as many as 500,000 people, and strengthening of basic emergency obstetric and neonatal care (BEmONC) services in 65 peripheral health units (PHUs).
The MoHS, in collaboration with UNICEF and other government stakeholders and development partners, identified the following priority interventions using the Health Sector Strategic Plan:
>> Increase government financing to the health sector, develop new financing mechanisms including a social health insurance scheme and seek additional resources.
>> Ensure the supply and logistics of sufficient drugs and equipment to health centers through the strengthening of procurement and supply chain management; establish efficient warehousing, storage and distribution systems; equip health facilities to deliver quality health and emergency obstetric services; make timely referrals; better manage essential drugs; and strengthen the capacity of facilities and maintenance units at central and district levels.
>> Develop human resources for health service provision by improving working conditions; introduce performance-based incentives to promote quality health care services; provide adequate numbers of qualified health workers; and, introduce improved, regular training programmes for health personnel.
>> Rehabilitate the health care infrastructure to meet basic standards.
>> Strengthen oversight, coordination and management at all levels to ensure better planning, management, transparency and efficiency.
>> Communicate policy to empower people to exercise their rights to free health care.
>> Rigorously monitor and evaluate programmes at all levels.
In order to enable seamless implementation of the FHCI, it was imperative that infrastructure, drugs, medical technologies, human resources and funding be improved. Therefore, one comprehensive emergency obstetric and neonatal care (CEmONC) and five BEmONC facilities in each district were designated to have their water, electricity, staff, logistics, equipment, blood bank and referral systems upgraded in order to deliver the FHC services. Among the many improvements made, the Government also increased salaries for health professionals in public service by at least 100 per cent and recruited 2,000 additional health staff. Development partners, including UNICEF, UNFPA (United Nations Population Fund), the Department for International Development (DFID), the World Bank and the African Development Bank (ADB) covered about 87 per cent of the cost of the scale-up and implementation costs.
Progress and Results
The launch of the FHCI appears so far to have contributed not only to the health and survival of mothers and children in Sierra Leone but also to their improved status as equal citizens of the country. At the same time, inequities in access to health care services for mothers and children appear to have been greatly reduced.
Although a rigorous evaluation has yet to be conducted to establish the real impact of the FHCI interventions, data collected through the District Health Information Systems (DHIS) indicate the following:
>> The number of acceptors of modern family planning methods at facilities rose by 140 per cent during the first year of the FHCI.
>> There was a 150 per cent increase in maternal complications managed at health facilities and a 61 per cent reduction in the maternal case fatality rate in the first year of the FHCI compared with the previous period.
>> There was a 45 per cent increase in health facility deliveries of newborns, while corresponding community deliveries by unskilled personnel declined.
>> Women making at least one antenatal care consultation increased significantly by 35 per cent in the 12 months following initiation of the FHCI compared to the pre-FHCI period.
>> Consultations for children under five more than tripled in the first 12 months of the FHCI, reaching 2,926,431 compared with 933,349 consultations in the preceding period. However, there has been a downward trend in the number of children seeking medical consultation since September 2010 although the absolute number remains higher than in the previous comparable period.
>> The proportion of children who were fully vaccinated before their first birthday during the first 12 months of the FHCI declined to 76 per cent, compared to 88 per cent in the period before the initiative. This decline in coverage might have resulted from a breakdown in the cold chain system and a reduction in the number of mobile outreach activities due to the heavy workload
>> Because the prevention of malaria and other diseases Is also linked to FHC service provision, the proportion of children under five years of age who were treated appropriately for malaria with Artesunate, the drug of choice, nearly tripled. About 90 per cent of the 1,288,828 children under five who were diagnosed with malaria during the first 12 months of the FHCI were treated with Artesunate compared to 51 per cent of the 682,539 diagnosed cases in the 12 months preceding the FHCI.
>> Also, for the first time ever, Sierra Leone achieved universal coverage with long lasting insecticide treated nets (LLINs) - one of the most cost-effective ways of preventing malaria - through the distribution of 3.2 million LLINs country wide. A compelling, counterintuitive finding by a post-LLIN campaign survey of ownership indicated that the use of nets was lowest in households in the wealthiest quintiles and in urban areas.
>> Overall, the changes facilitated by implementation of the FHCI contributed to the dramatic reduction of approximately 90 per cent in the malaria case fatality rate in public hospitals.
The FHCI has been instrumental in bringing political attention to longstanding failures in the health system, such as poorly motivated health personnel, under-equipped facilities and inadequate supplies of drugs. Government monitoring of service access and quality, while still short of what is needed, has improved relative to previous years. Donor co-ordination in supporting the FHCI has been remarkable.
One possible shortcoming worthy of note is that fact that, although the FHCI applies equally to all target groups irrespective of differences in poverty ranking, it may not be addressing vertical inequities.
The FHCI is heavily dependent on donor funds, which covered 87 per cent of the cost of the effort in 2010. Substantial budget and donor investments - and the maintenance of donor enthusiasm - are needed over the next four years for successful implementation of the programme.
Sierra Leone’s health systems remain weak. Poorly equipped health facilities, as well as untrained and unmotivated staff adversely affect the quality of health service provision. The number of health staff is still insufficient to meet the demand for service delivery although it has increased since the launch of the FHCI. Most health facilities do not have continuous water or electricity supply, and there are frequent break downs in the cold chain system.
Progress reporting has proved to be another hurdle to overcome during the first year of FHC implementation. It is crucial to be able to measure progress by delivering accurate data in order to maintain donor trust, maintain programme momentum and aid further planning.
Timely clearance of drugs and medical supplies has also been difficult at times, and transport delays frequently hamper distribution leading to stock-outs of vital drugs and supplies at the local health centers. In addition, there have been issues of transparency, leakages and thefts of drugs and nutritional supplements. Accountability needs to be improved at all levels. Furthermore, the current use of a “push” system of drug fulfillment versus a more desirable ”pull” system has led to frequent stock-out of vital drugs at health facilities.
Because the FHCI requires the collaboration of many players, oversight, coordination and management must be strengthened at all levels to ensure the efficiency, transparency and sustainability of this massive intervention.
Removal of user fees has greatly enhanced health service delivery and increased uptake of basic health services leading to an appreciable increase in coverage through critical health interventions.
The quality of health care must improve in tandem with increasing demand and access, otherwise some targeted beneficiaries may not utilize the service.
Strengthening of the health system’s capacity and governance is essential for the FHCI to be successful. Therefore, the sustainability of resources and systems must be considered from the outset of planning.
Although the concept of free health care is not new globally, its adoption in practice resulted directly from the leadership and determination of the Government of Sierra Leone, which galvanized health system stakeholders to take action. The impressive demonstration of political will and commitment brought together government, development partners, INGOs (international non-governmental organizations), civil society groups and UN agencies to work toward achieving a clear and strategic goal, and resulted in the programme’s Government ownership, national rollout, and monitoring by civil society organizations.
The big challenge of leakages presented an opportunity for the development of a clear risk control matrix, fully endorsed and owned by Government, which can be used as a reference case for other countries.
The successful implementation of the FHCI in Sierra Leone and the lessons that have been learned provide a ready platform for understanding how to strengthen central and district level health care systems to deal with problems that cannot be tackled by PHUs. Modalities are being put in place to strengthen these levels.
This initiative has also illustrated how political will, removal of user fees, and improvements in facilities, supplies and human resources can increase demand for, and use of, health care and other basic services to reduce inequities for women and children.
The FHCI has contributed to narrowing the geographic and socio-economic inequities in access to health care. Maintaining success depends on the sustainable delivery of free health services and removing remaining bottlenecks so that more pregnant women, nursing mothers and children under five years of age can use the services.
The FHCI initiative has also laid the groundwork for the development of a national health financing strategy that may eventually include a national social insurance scheme that can provide protection and care for all people in Sierra Leone.
Government needs long-term support from its partners to upgrade the entire health system. Strategies are being considered for mobilizing resources to finance health care systems both internally and externally and to strengthen public financial management procurement systems.
The establishment of a sustainable national Procurement and Supply Management (PSM) system and arrangements to create long-term PSM infrastructure have started and will be pursued, with the aim of creating a National Pharmaceutical Procurement Supply Unit (NPPU).
The Ministry of Health and Sanitation will continue to strengthen training and capacity development of human resources to meet the need for more skilled health professionals.