The free healthcare initiative in Sierra Leone: Evaluating a health system reform, 2010‐2015

Abstract

This article presents the findings of a theory-based evaluation of the Sierra Leone Free Health Care Initiative (FHCI), using mixed methods. Analytical approaches included time-series analysis of national survey data to examine mortality and morbidity trends, as well as modelling of impact using the Lives Saved Tool and expenditure trend analysis. We find that the FHCI responded to a clear need in Sierra Leone, was well designed to bring about needed changes in the health system to deliver services to the target beneficiaries, and did indeed bring funds and momentum to produce important systemic reforms. However, its ambition was also a risk, and weaknesses in implementation have been evident in a number of core areas, such as drugs supply. We conclude that the FHCI was one important factor contributing to improvements in coverage and equity of coverage of essential services for mothers and children. Modelled cost-effectiveness is high-in the region of US$ 420 to US$ 444 per life year saved. The findings suggest that even-or perhaps especially-in a weak health system, a reform-like fee removal, if tackled in a systematic way, can bring about important health system gains that benefit vulnerable groups in particular.

Evolution of policies on human resources for health: opportunities and constraints in four post-conflict and post-crisis settings

“…In 2011 and 2012, a Performance Based Financing (PBF) scheme and a Remote Area Allowance were introduced to provide motivation for primary care workers and remote staff. However, by 2012, the reforming momentum that drove the design of these reforms was lost, and their implementation lagged behind and faced numerous challenges [30, 31], entering a new phase of slow paced policy-making. In this phase, the new HRH Policy and HRH Strategic Plan (2012) were prepared, giving ex-post shape to the changes that had already taken place at operational level [8].…”

“…The Technical Working Group initially created during the preparation of the FHCI has been revived in 2015 and charged with the coordination and implementation of HRH strategies and activities. Initially, these included another payroll clean and a revision of the 2012 HRH policies and strategies [31]. …”

“…In Sierra Leone, for example, political leadership was central for the development and sustaining of the FHCI [30, 31]. As with most major policy developments, a constellation of factors was identified which supported this move, including the influence of the international context (favourable to removal of user fees at that time and promoting the MDGs) and the support of external players like the British Government and other donors.…”

“…For example, there was very little awareness at central level about the PBF and remote allowance schemes – both critical to health worker motivation and facing considerable implementation challenges. Additionally, the few evaluations of policies were externally commissioned (for example, the FHCI one [31]).…”

Does free of charge policy increase care-seeking for children under five in Sierra Leone? Evidence from population-based studies from 2008-2016

“…Using fever as an indicator of morbidity in children under ve this study aims to evaluate the trend in the prevalence of care-seeking for fever as well as to identify determinants of utilization of healthcare services by U5 caregivers in the context of FHCI. Independent variables included those for the description of the socio-demographic and those for the assessment of the determinants of the care-seeking for fever: the respondent's age ( [15][16][17][18][19][20][21][22][23][24], [25][26][27][28][29][30][31][32][33][34], and ≥35 years); the level of education of the mother of the child (none formal level of education, primary, and secondary or higher level of education); the number of children ever born in the household ( [1][2], [3][4] and 5≥children); the gender of the household head of the child; the age of the head of the household of the child ( [15][16][17][18][19][20][21][22][23][24], [25][26][27][28][29][30][31][32][33][34], and ≥35 years); the wealth index (richest, richer, middle, poor and poorest); the regions (east, north, south, and west)...…”