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Free Health Care in Sierra Leone: Lessons from a Success Story

June 22, 2011

By Fiorenzo Conte

Last month The Lancet featured a piece on the successful attempt of Sierra Leone to put into place free health care for pregnant women, women breastfeeding and children under 5.  The establishment of free health care for these groups resulted in a dramatic increase of children treated for malaria, thus showing that high prices were indeed constituting a big barrier to access. Two lessons can be drawn from this story:

Money is not the only bottleneck. There is a general assumption that free health care in developing countries is not possible because it costs too much and funding is not sufficient. This is the same assumption that underlies the argument in favor of debt relief: countries servicing the debt have credit constraints and therefore they cannot invest in other sectors, such as public health. Yet, this argument ignores the fact that sometimes funds are available but they are simply not utilized for investments. Credit constraint is indeed a problem but often does not determine whether or not investments in public health are made. New research conducted by the African Child Policy Forum reveals that poorer countries allocate a higher share of their budget to health and education spending vis-à-vis relatively richer countries such as the oil-rich governments of Sudan and Angola. These findings indicate that more than credit constraints what counts most in determining level of investment is the political will to do so. The case of Sierra Leone corroborates this thesis. As The Lancet points out:

In Sierra Leone, the key factor, according to those interviewed, was the president: he put the health-care directive at the top of his priority list. Political will drove the process. Robinson( former president of Ireland), said it directly: “For large initiatives like this one, the presidential will has to be there, and the donor community has to be ready to be more supportive of that.”

Donors-government cooperation and responsibility sharing are key to success. One of the previous posts presented the “dual oversight mechanism” as one of the possible mechanisms to overcome the risk of dual public sectors in fragile states. In order to avoid channelling aid through agencies outside the state, donors can create a fund where money is jointly managed by donors and governments. The advantages of this mechanism is that the government can acquire the capacity to administer money while the donor can oversight the proper use of money. Donor-government cooperation has proven particularly important in Sierra Leone. The sharing of responsibilities prompted more transparent procedures and strengthened the relationship between stakeholders, as they were supporting each other. In the words of technical adviser to the ministry from the Africa Governance Initiative:

“ (..)having a co-chair from a donor organisation was really important”, Melly said. “Having that donor there made the ministry people feel less that it was doing all the work. The meetings also added transparency to the whole process. Before, what struck me was how some donors would have their own meeting and talk among themselves and then come back and tell the ministry, ‘Why isn’t it done?’ But now there was more of the feeling that here are the five things to do, this is more of a joint activity, and we need each other’s support to do this.”

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