Waiving fees to boost access to essential maternal and newborn care in Sierra Leone
Sierra Leone is among the developing countries with the worst maternal and child health indicators. Maternal and newborn mortality figures are quoted as 2,100 per 100,000 live births and 155 per 1000 live births respectively.
A nationwide needs assessment for Emergency Obstetrics and Newborn Care (EmONC) was undertaken in July 2008 by the Ministry of Health & Sanitation (MOHS) and the Joint UN partners. Funding was provided by Irish Aid. The assessment is part of the implementation of the Reproductive and Child health strategy, which was launched by the President earlier this year.
The aims of the assessment were to determine the availability, utilization and quality of EmONC services. Also, to identify gaps in service delivery, to identify interventions for the reduction of maternal and newborn mortality, and to provide baseline data upon which future programs could be monitored.
The assessment consisted of a quantitative and a qualitative section. Within the former, the UN Process indicators and signal functions for emergency obstetric care were used nationwide. Whereas for the latter, focus group discussions were conducted in representative districts regionally, to find out the health-seeking behaviour of communities when an emergency occurs in the case of the pregnant woman and/or the newborn. All public, private, mission, and NGO hospitals providing Maternal and Child Health services were selected and 145 health facilities were assessed.
One of the significant issues highlighted in the assessment is the payment of health services. In Sierra Leone, out of pocket expenses for those seeking health care are among the highest in Africa (about 70%). Yet most of the population remains below the poverty line. Even modest charges tend to exclude over 50% of the population from seeking health care and exemption systems in current use do not seem to work. This deters people from going to hospital which eventually leads to failing health for adults and children alike.
Here is what Geert Cappelaere, UNICEF Representative in Sierra Leone had to say on the issue:
Q: We understand that Sierra Leone is rated as having one of the worst maternal and child health indicators, why do you think that may be?
Although the government has a free health care policy for children and pregnant women, this is rarely enforced and consequently health services end up being rarely free in Sierra Leone. One of the main issues contributing to this situation is that health staff is usually underpaid and poorly supervised which leads them to request money from patients.
Another issue is that Government health facilities have a cost recovery scheme in place. This means that drugs are sold to the public at cost price. With the cost recovery funds, the facility is able to go back to a central store to replenish its stock. However, in practice, there are no mechanisms in place to monitor these charges and the replenishment of supplies. Charges are not regulated.
Different short, medium and long term strategies are currently explored for the health financing. Among others, UNICEF Sierra Leone is supporting the design of new programs that include components which enables the empowerment of mothers so as to ensure more control on service provision and the choice of service providers. Moreover, UNICEF and development partners are working together with the government to develop incentive schemes for health staff. In the long run these are to be based on performance and results.
Q: What specific advocacy efforts are being attempted and channelled?
In addition, UNICEF is planning to conduct a nationwide evidence based advocacy campaign through findings highlighted in the Nationwide Needs Assessment for Emergency Obstetric and Newborn Care Services.
Q: What are some of the logistical problems that UNICEF is facing?
Improvement of supervision and introduction of appropriate incentive schemes for health staff is also a challenge but crucial for the improvement of the health system.
Q: What will be the measure of your success?
In addition, we are working alongside the government in an attempt to get him to raise expenditure on health to $15 per capita and leverage with all development partners to step up their contribution to health financing.
The focus of our investment is the improvement of service quality, as well as the implementation of free health care for under-five children and pregnant women in all peripheral health facilities and district hospitals.