Elsevier

The Lancet

Volume 377, Issue 9775, 23–29 April 2011, Pages 1393-1396
The Lancet

Special Report
How did Sierra Leone provide free health care?

https://doi.org/10.1016/S0140-6736(11)60559-XGet rights and content

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Secrets of success

How did it happen in a country that had a barely functioning health system following more than a decade of brutal civil war? Several outsiders told The Lancet that the country's initiative was better organised and had a higher degree of cooperation among the government, donors, and development partners than virtually any other.

“What happened in Sierra Leone was breathtaking”, said Rob Yates, senior health economist at the UK's Department of International Development (DfID) a month after the

The backdrop

Sierra Leone was devastated by a civil war that started in 1991 and continued for 11 years. The war killed tens of thousands of people and displaced another 2 million (nearly a third of the population). The fighters' signature act of brutality was the chopping off of the hands and feets of thousands of people, leaving a large group of people maimed for life.

At that time, literacy rates were low (35%), fertility rates high (five children born per woman), and 42% of the population were younger

Trouble at the ministry

Before anything could happen, Koroma had to get his house in order. Earlier in 2010, the country's Anti-Corruption Commission was investigating his health minister, Sheiku Tejan Koroma (no relation to the president), for allegedly influencing a procurement contract in favour of a friend. Minister Koroma, who had been an engineer in the USA for many years, had almost impulsively announced in August, 2009, in a meeting with donors that he was about to start a free health-care plan.

In November,

Health leaders

In the ministry, underneath the president and vice president, several key leaders guided the process. Among them were two who stood out: Kisito S Daoh, the then acting chief medical officer, and Samuel A S Kargbo, director of reproductive and child health.

“The chief medical officer (Dr Daoh) and Dr Kargbo were kind of the encyclopedia of the ministry”, President Koroma said. “They motivated people. It was just what I needed.”

Daoh's office, in the absence of a minister, became the centre of

New era begins

At dawn on April 27, 2010, mothers and their young children began forming lines outside hospitals and clinics around Sierra Leone. They were anxious to receive medical attention that had been out of their reach.

At the Ola During Children's Hospital in Freetown, President Koroma told a crowd in English and the local Krio language that pregnant women, breastfeeding mothers, and children younger than 5 years will no longer have to pay for health care in government facilities. When he said the

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    A similar finding was reported in a Ugandan study in which participants did not see the need to visit health facilities as medicines were frequently not available [43]. Medicine unavailability in our study may be explained by the absence of prescribed medication on the list of free healthcare drugs since most FHCI drugs were procured for disease conditions common to pregnant women, lactating mothers and under-five children [13]. Also, frequent supply shortages for essential drugs or pilfering of medicines by healthcare workers may explain drug unavailability [41,44].

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JD's reporting was sponsored by the Ministerial Leadership Initiative for Global Health (MLI), based in Washington, DC, USA, and a programme of Aspen Global Health and Development. MLI supports the priorities of five ministries of health in the developing world, including Sierra Leone

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