A Look Back at Sierra Leone’s Free Health Care Launch
04/28/2010
John Donnelly reports when free services become available
April 26 In Freetown, Free Health Care for Mothers and Children
April 27 The First Day of Free Health Care
Hundreds of women and children patiently wait in line outside the doors of the Ola During Children's Hospital in Freetown, Sierra Leone. © Dominic Chavez
FREETOWN, Sierra Leone - Most outsiders have exceedingly low expectations when it comes to anything to do with Sierra Leone. But I actually had quite high expectations when it came to the country's rollout last week for free health care for pregnant women, breast-feeding mothers, and children under five.
It's not that I thought everything would go smoothly here - there will surely be uneven distribution of drugs, theft of drugs, and at this writing the country was four days late in meeting its payroll of 7,077 health workers.
But the country's top political leaders are committed to making it happen, and Sierra Leone has a Ministry of Health and Sanitation with enough talented people in key positions, backed by a small circle of international consultations and donors believing in offering free health care to poor people, to execute the plans.
I'm just finishing my second trip to Sierra Leone in the last nine months to peer inside the Health Ministry's inner workings in order to get a better understanding of why things work in health bureaucracies. The Ministerial Leadership Initiative for Global Health, based in Washington, D.C., sponsored my trips.
After visiting hospitals and clinics for three days, and then walking the Ministry hallways in the late afternoons, I got the feeling that the months of planning had made a huge difference - and that the Ministry was being smart in getting out nuanced messages to its citizens.
For instance, on Thursday, Dr. Samuel A.S. Kargbo, director of the Ministry's Reproductive and Child Health Services, went to the country's national radio station, which reaches all districts, to tell people that mothers shouldn't bring children who are well to health facilities - that they should only bring in sick ones. Several major hospitals were swamped with mothers who believed it was an opportunity to stock up on free drugs, or who were so used to campaigns such as vaccination drives that told them to bring all their children.
And the story won't be just about shortcomings. It will also be about mothers - mothers who are alive because they opted out of giving birth at home and went to a hospital, where any complication can be handled much more safely.
On Thursday, on ward 3 at the Princess Christian Maternity Hospital (PCMH) in Freetown, I met Kadiatu Bangura, 18, who had given birth on April 26 in her home in a village about 50 kilometers outside Freetown. That was the day before the free health care rollout.
But complications arose in her tiny house. The traditional birth attendants, two elderly women, couldn't remove the placenta. That afternoon, Bangura started bleeding badly, and she lost consciousness.
A relative placed her in the bed of pickup truck -- he put pillows underneath her -- and they rushed to PCMH, arriving in the early hours of April 27, free health care day. Still unconscious, she was brought into surgery and doctors removed the placenta and gave her blood transfusions. Three days later, she was laying in a hospital bed, her baby boy asleep at her side, feeling great.
``I thought I was going to die,'' she told me. ``I didn't deliver in a
health clinic because I didn't want to spend the money, so we stayed
in our home.''
What will she tell her friends when she goes back?
''I'll tell them about free health care if they don't know. They should go to the hospital to give birth - I know this well,'' she said.
Since she arrived at the hospital after midnight on the 27th, Bangura owes nothing to the doctors, nurses and health attendants who helped her or to the government - except for her life.
April 27
The First Day of Free Health Care
Moses Smarts, six months old struggling to rest while fighting dysentery at the Ola During Children's Hospital in Freetown, Sierra Leone. © Dominic Chavez
FREETOWN, Sierra Leone - The women and their babies started arriving before dawn at the Ola During Children's Hospital and they kept streaming in even as the sun set. Many waited hours in the hot sun, but they were determined to get in.
Free health care was on the other side of the door, for the first time in their lives.
President Ernest Bai Koroma told a crowd of hundreds at the hospital that pregnant women, breast-feeding mothers, and children under the age of five will no longer have to pay for health care in government facilities.
He said it in English and then repeated it in the local Creole language, which elicited whoops of joy from all around him, including from more than 100 pregnant women in a room behind him as they waited to see a doctor. Several danced as people in the crowd cheered and shouted out, "Yes!"
"For many years, many, many pregnant women, breast-feeding mothers, and children under five have suffered and died because they simply could not pay fees for consultations, drugs and other services," Koroma said. "Today we are taking the biggest step ever to end this unenviable position."
Last September, at the United Nations General Assembly, Koroma and the heads of state from Burundi, Nepal, Malawi, Liberia and Ghana announced that they would either start or extend free health care for pregnant women and children. That group is part of a small but growing trend in Africa to stop user fees at health facilities for pregnant women and children because the payments kept people away from care.
I am on a trip through blazing-hot West Africa, and I saw the same problem of lack of access at the last stop, Mali, where a Demographic and Health Survey released in 2008 showed that people were barely using brand-new health facilities because of cost. Now, Mali, also along with other countries in Africa, is trying to expand a health insurance plan to open up access to the poor.
In both Sierra Leone and Mali, I've found that some of the senior-most health officials or politicians readily admitted past failures, and used them as incentives to start improving care. Everyone seemed to be rallying around reducing maternal mortality; the UN has set a goal of reducing it by three-quarters from 1991 to 2015.
At the ceremony Tuesday, Vice President Samuel Sam-Sumana opened his remarks by asking for a moment of silence.
"This moment is for all those in Sierra Leone who have prematurely died, all mothers and babies who died unnecessarily because of poor health care," he said. "May their souls rest in peace."
In the wards of adjoining hospitals Tuesday - Children's Hospital and Princess Christian Maternity Hospital (PCMH) - two very different scenes unfolded. Children's Hospital was flooded; PCMH had far more manageable increases in patients.
Just minutes before Sam-Sumana spoke, and only 40 feet behind the stage of VIPs inside the hospital walls, Marie Smarts, 30, delivered a baby boy by Caesarian section. She will name him Sallieu, she said, after her father. She didn't want to say much a few hours after birth but when asked what she thought about free health care, she replied, "Thank God."
Her niece, Ramatu Fofanah, 22, was more talkative. "It would have been hard for her to pay the fees," Fofanah said. "It's a very important thing that the country has done. People are too poor here. We know of women who have died giving birth in homes. One neighbor lost her life, and lost the baby, too, when she gave birth in her home. With this free medical care, so many lives will be saved."
That undoubtedly will be true. But Sierra Leone's health system will be strongly tested in the coming months, even if not with such a barrage of patients that it had Tuesday.
Outside the outpatient registrar at Children's Hospital, doctors waded into the thick crowd of mothers and babies, performing triage as if they were working after a natural disaster. They checked scalps, felt foreheads for fever, looked at stomachs and backs. They found some with measles (those were quickly taken to a measles ward because of the high chance of infecting others), some severely malnourished, and one who was having convulsions.
But mostly they found healthy babies.
And they told those mothers to come back another day.
Still, by 4 p.m., the hospital had registered 294 children to see a doctor, with another 90 still waiting to get to the registrar's desk. To put this in perspective, the hospital saw 56 children on Monday.
"We are strapped," said Prof. Dr. Tamra Abodun, a pediatrician at the hospital. "The majority are not that sick. Women probably thought that maybe it would be for just one day, or one month. I wouldn't be surprised if many came back tomorrow."
Abodun deployed doctors from other wards into the outpatient area. Eight in all were examining the young children, and by the end of the day several seemed exhausted.
The day had its share of problems. One was that the pharmacy had run out of several antibiotics and at 4 p.m. was almost out of even basic Paracetamol, which reduces pain and fevers.
"We are stressed," said Matthew Barnes, a pharmacy technician, as he measured out yet another prescription.
But motioning out to the line of people waiting for him, he said, "It is an incredible day - all these people are getting care, many for the first time."
The same spirit showed at the registrar desk. Asked how long they would register new patients, registrar Rachel Edwina Leigh called out, "We will stay until we are finished with the last patient!"
She laughed and filled in the details for patient No. 295.
April 26
In Freetown, Free Health Care – at Long Last
Dr Kisito S. Daoh, chief medical officer at the Ministry of Health and Sanitation in Sierra Leone, listens to colleagues during a staff meeting in Freetown, Sierra Leone. Photo © Dominic Chavez
FREETOWN, Sierra Leone - Several years ago, the government of Sierra Leone promised that it would give free health care to pregnant women and young children.
Nothing happened.
But today it happens - celebrated in big ceremonies across the country, on the nation's 49th Independence Day. Tens of thousands of pregnant women and their children are expected to descend on health facilities all over the country, many for the first time because they never could afford it before.
The story behind how it came about runs counter to many people's perceptions of Sierra Leone as a hapless, still-sunk-by-civil-war kind of place (even if the war ended seven years ago).
I'm in West Africa - Mali and Sierra Leone - on a reporting project for the Ministerial Leadership Initiative for Global Health (MLI), based at the Aspen Institute in Washington, D.C. MLI's mission is to strengthen political leadership in its five countries. Here in Sierra Leone the leadership faces a major test this week and beyond as they roll out a free health care plan in one of the poorest places in the world.
Last July, the former Health Minister impulsively wanted to start the free program in a matter of days. Wiser heads stopped it, arguing that a lack of proper planning would be disastrous.
Since then, ministry officials have planned and planned, forming committees and subcommittees; traveling often for meetings in the districts; sending weekly e-mail updates to over 100 core planning participants; cleaning payrolls of more than 850 "ghost workers" (mostly retirees who were still receiving their paltry salaries); adding more than 1,000 new workers; and sending out 18 refrigerators, 24 air conditioners, six generators, 36 fire extinguishers, and even 12 office tables, 12 filing cabinets, and 24 office chairs to districts for distribution.
Still, they are a little nervous here.
They know that short-term - today in particular - could be part chaos, especially with the numbers of young children who could come.
President Ernest Bai Koroma, the godfather of the free- health care plan, will kick off the initiative at the Princess Christian Maternity Hospital - the country's main referral center for complicated pregnancies. The hospital has had an extraordinarily high maternal mortality rate. In 2007, for instance, 1,279 women gave birth here. Of them, 141 died. One death for every 11 women who came here to give birth.
That is the major impetus for this rollout - a maternal mortality rate that ranks it fifth worst in the world, according to a study released earlier this month in the Lancet journal.
This past weekend, I went to the Health Ministry, and it was a busy place.
Inside, dozens of people were working out the last-minute difficulties.
Dr. Kisito S. Daoh, the chief medical officer, had people backed up outside his office, waiting to see him. He is the chief choreographer of this rollout, and on Saturday he was feeling horrible. "High blood pressure," he told me, laughing. "Plus a fever!"
"I'm dealing with calls from the districts now. We need to make the message clear that all the drugs we're sending them should only be used for pregnant women or children who are sick," he said. "We're concerned that they will give out the drugs to people who are well."
Across the hallway, Dr. Samuel A.S. Kargbo, the ministry's director of reproductive and child health services, was pouring through reports from all parts of the country.
"The ceremony is just a ceremony,'' he said. "It's the implementation down the road that I'm worried about.''
What concerns him are basic things: some small health facilities don't have running water; some of the free medicine won't reach remote health posts in time; and the ministry had to basically use educated guesses on the amount of drugs to send to each facility - because no one knows how many people will be seeking services.
One other wrench: health care workers went on strike for 12 days earlier this month, protesting their low salaries and demanding higher pay because they no longer could see private patients in government facilities and they are likely to face an onslaught on new patients. President Koroma settled the strike with pay increasing more than double for most health workers; the ministry's 7,077 staff were expected to see the increased pay in a paycheck received on Monday.
At the Princess Christian Maternity Hospital, health care workers said they were really happy that the plan would become a reality.
"The work will be heavy," said Isata Bah, 24, a nurse. "Never mind that. We can do it for them. It's a very good thing - this rollout. Poverty is the main problem in Sierra Leone. Some people die because they can't afford medical care. Maternal mortality is so high. But now they will seek care earlier now. We will save lives."
Learn More
Read John Donnelly's blog from his trip to Sierra Leone in August, 2009.
John Donnelly is a freelance writer. His trip to Mali was supported by the Ministerial Leadership Initiative for Global Health in Washington, D.C., which gives support to Health Ministries in five countries - Sierra Leone, Mali, Senegal, Ethiopia, and Nepal. Donnelly welcomes any questions from readers in the Comments section, and will reply to them.
Dear John, I was also at the Ola During Children’s Hospital to witness the chaos and success on 27th April 2010 and have just come across your article. I enjoyed it very much. I work for the Welbodi Partnership, we are a UK charity working exclusively with ODCH. You may have met with some of my colleagues on the day - i know you spoke to Tamra. We are working with the hospital to improve facilities, provide medical training and to work closely with management in support of funding and implementing change and improvements. We work at the hospital each day - are you still in Freetown? If you would appreciate an update at some point on how things are going please do not hesitate to get in touch, i would love to tell you more about what is happening if you would be interested.
Best wishes
Sarah
— Sarah Jones on 2010-05-11
This is a wonderful new paradigm in the provision of equitable services to to the poor and needy. Health is an area that has been neglected for so long in Africa states especially so when you look at the budget provision for healthy compared to Defense or presidential security.
These are new grounds that need to be learned from and possibly rolled out in other African countries.
Let the project be owened by the users and be influenced by local indigenus knowledge for the reason that health and ill health is defined and understood by the local users.
Avoid Total Policy and knowledge transfer from the west as idoelogies/philosophies sometimes dont match the contextual map.
I am certain that the full involvement by well-trained clinicians in management and finance would be an added value.
I trust that people like DR Ali Wurie would make it a successful project.
Dr Wurie please kindly get in touch so that we touch base on our days at Birmingham University where you excelled in management in health services.
Good luck to Serra-leone health services for the people and by the people.
— William Nkata on 2010-05-11
Dear John,
As someone keen both on “Salone” and on maternal survival, I am very much enjoying your blog which is refreshingly positive and yet also puts all the challenges out there for the new programme in Sierra Leone. I was in Freetown for some time before the launch and was able to see all the efforts put into getting it right, despite lack of resources and some severe coordination challenges - not to mention the infrastructure gaps in so many communities and facilities.
It is very difficult to draw everything together that is required to reduce maternal and infant deaths. It involves not only money and availability of proper facilities and staff, but also behaviour change on the part of everyone - families and communities, medical personnel and traditional practitioners, policy makers and donors. In such a resource-poor environment, it is truly daunting. All credit should go to those involved, and especially to Dr. Daoh for trying to hold it all together.
One thing you haven’t mentioned when discussing this “new” policy/strategy - and that is that most African countries did have free health care for these groups decades ago - but then, under pressure from the World Bank, had to abandon that policy and institute user fees. There was tremendous pressure from donors on all governments to obtain “cost-recovery” from patients. Free services were seen as fiscally irresponsible and loans and donor funds were actually withheld from many governments which tried to maintain free services.
We know now what happened. But are those “experts” who withheld funds and pressured poor governments to abandon free or affordable delivery care held accountable for the maternal deaths which occurred? Are you kidding? The same institutions are now back on the bandwagon of meeting MDG 5 by ensuring greater access to maternal health care through provision of free care!
Thus the pendulum has swung.
I, too, have hopes for this campiagn and policy to save lives in Sierra Leone, where maternal mortality is among the highest in the world. But I know that not too far in the future, someone will ask: how can the government pay for this? Continue taking big loans or grants? Health personnel are not paid a living wage in Sierra Leone. Improving their wages, alone, much less those of all civil servants, is more than the national budget can bear. I would love to see you also discuss some of these issues and report back on what ideas or plans are around for getting the economy off the ground so that there can be a stronger tax base and a national budget which can better support basic services. Does the new “luxury” tax have promise for this? Can health workers be better paid so that they don’t sell drugs or services just to survive?
It is a fascinating situation - with so many elements to ponder. Keep those great reports coming!
— Pamela DeLargy on 2010-05-18
Hi John
I am a final year student of FBC peace and conflict studies. I am writing my dissertation on the free health care policy you wrote on. I want to thank you for writng such a comprehensive article on this topic. This is one ot the few articles I have read during my research that perfectly expalin the issue.
— barba i Turay on 2010-07-06