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Sierra Leone: Joy and blessings for free healthcare

Politicians visiting hospitals, being cheered and blessed. Not something we’ve seen in Britain over the past few weeks. But it was the scene in the small, impoverished West African state of Sierra Leone this week, when the government announced the abolition of health user-fees for pregnant and new mums, and children under five.

In a country which has one of the worst rates of child mortality in the world, the joy was palpable. At the Princess Christian Maternity Hospital in the capital Freetown, pregnant women called out, “Thank you, thank you,” as country’s president toured the wards. Signs which had lists of fees for paediatric or obstetric consultations were freshly painted over.

Living in the UK, where we take for granted free healthcare, it’s hard to comprehend the pernicious effect of charging for medical help in Africa. What might seem to us as a minuscule payment (around $10 for a normal delivery), is simply unaffordable to a pregnant Freetown trader selling mangoes by the roadside.

User fees: misguided experiment

User-fees — a misguided experiment championed by international financial institutions like the World Bank in the 1990s as a way of driving up healthcare quality in the developing world — had the effect of putting treatment out of the reach of those who need it most; the poor.

Mothers have terrible stories to tell. One told us that her baby died from diarrhoea – an easily treatable ailment, but one of the biggest killers of under-fives in this country. She told us, “The doctor told me to pay £15, but I only had £4.  He wouldn’t look at my baby. He just got in his car and drove away.”

Heart-breaking testimony like this has fuelled the movement to get rid of user-fees — not just in Sierra Leone, but across Africa. A coalition of national civil society organisations and international development organisations, like Save the Children, has lobbied tirelessly for this change — in the face of scepticism from donors such as the World Bank.

Spectacular response

The initial £20 million price-tag  is a pinprick compared to the NHS’s £100 billion plus yearly budget. But for a cash-strapped government in the developing world, it’s a huge investment. There have been sharp pay rises for health workers; doctors, nurses and midwives who have been compensated for loss of top-up fees — often patients paid on-the-spot — and of course, for dealing with the surge in people seeking treatment. Medical workers are already talking of a ‘spectacular response’, with mums and babies waiting in long queues for simple but life-saving treatments like anti-malarials, which are now given free.

The initial costs will be underwritten by international donors and by an increase in the government’s budget allocation to health. The main responsibility for making it a success lies, of course, with the Sierra Leone government. Our health policy advisor, Nouria Brikci who has worked closely with the Ministry of Health, describes the efforts of officials there over the past months as ‘extraordinary’, as all the complex pieces of new system were lined up.

Britain’s key role in change

But the UK government deserves a pat on the back too. Britain has played a key role in this change; providing $8.8 million to buy drugs, helping the Ministry of Health put together a sound financing strategy, and generally championing the government’s efforts internationally.

It’s only the start, but Sierra Leone is going to need its British friends in the coming months and years – whoever wins the next election.

This blog was first published in BMJ Blogs.

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