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No problems in Sierra Leone, only opportunities

Sierra Leone’s Free Health Care Initiative is becoming pretty famous for a boring policy change on health system financing. And Naomi Campbell isn’t even involved. There is something about the boldness, the high-profile and the level of commitment with which Sierra Leone announced the total removal of charges for healthcare for children under 5, pregnant women and breastfeeding mothers that has inspired people. I am in Freetown in Sierra Leone to learn how it is progressing and what we can glean from this for other countries.

We do not have national data yet for the increase in usage but by the end of August there should be figures available to support the anecdotal evidence of a massive increase in use of maternal and child health services. On Thursday last week, I met again with Dr SAS Kargbo, Director of Reproductive Health Services at the Ministry of Health and Sanitation who has led the introduction of the new policy. Dr Kargbo is a remarkable tour-de-force, persuasive and inspiring. He was working, as a doctor, in Kabala district when the BBC met him in 2008. I understand that the President of Sierra Leone also met him around that time and asked him to come to the Ministry.

I asked Dr Kargbo a question that Save the Children has had to answer a lot: why focus on user fees removal? He had some good answers.

Firstly, the UN Human Development Index that put Sierra Leone at the bottom inspired the government to do something dramatic to improve maternal and child health. Even though health service provision was low, the demand for services was even lower – pregnant women and parents of young children were simply not coming forward. A government survey showed overwhelmingly that the cost of the fees was the main barrier, far more than difficulties of travel or the quality of the service. This is no surprise to Save the Children which has led with a body of research and analysis on exactly this point which has helped to establish the near-global consensus that fees for health services, however small, exclude the poorest.

The other main point he made – which my colleagues in Sierra Leone know very well – was that this is not an isolated policy change. The government recognised that they needed to use this opportunity to improve the health system for the increased demand that removing fees would bring. Subcommittees of the main steering group work on human resources (salaries were very low and infrequently paid forcing health staff to use money from patients as income), drugs supplies (monitoring systems are being put in place) and communication (ensuring that the people know their rights and can hold health service providers to account) have all been part of the process.

As Dr Kargbo says, there are no problems, no challenges, only opportunities.

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