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Waiving fees to boost access to essential maternal and newborn care in Sierra Leone

UNICEF/Sierra Leone/2008
© UNICEF/Sierra Leone/2008
Geert Cappalaere, UNICEF Representative in Sierra Leone with children.

Interview with Geert Cappalaere, UNICEF Representative 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?
A: Well, one reason could be user fees. It often deters women from the prompt use of health services for themselves and their newborn children. The daunting difficulties that most people have with fees, translates to the inaccessibility of health services and increasing patronage of unskilled traditional birth attendants.

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.  

Q: What are some suggestions that UNICEF has formulated in order to overcome this situation?
A: UNICEF has spearheaded a common position of all health development partners on user fees: Ensuring the unconditional implementation of the existing policy of free services for under-five children and pregnant women.

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?
A: Advocacy for free care and public information is being taken at all levels- central government level through the Presidents Office, Office of the first Lady, district and Chiefdom levels. The bottom line is for UNICEF to achieve the goal of free health care or alternative health financing mechanisms which take away the burden from the poor consumers.

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?
A: Ensuring that health services are available and of quality is the most fundamental issue at the moment. Only 14 hospitals are able to offer comprehensive emergency obstetric care in the country while no peripheral health facility is able to offer quality basic emergency obstetric care. The need to upgrade the health facilities is a main focal point of the national Reproductive and Child Health program of 2009.

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?
A: Well, first of all we want the fee waiver for pregnant women and newborns duly applied. Moreover, clear guidelines on this waiver need to be published by the Ministry of Health and Sanitation.

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.



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