The Sierra Leone government is considering a health care plan that would combine a national insurance scheme with totally free care for the neediest groups, including children and pregnant/lactating women.

“We will probably have a hybrid of both,” Health Minister Soccoh Kabia told IRIN.

Sierra Leone has some of the highest infant, child and maternal mortality rates in the world. But Kabia said the most recent demographic survey shows progress on these fronts. “We have a ways to go but we are making progress. We will not rest until our [women] and children stop dying.”

If implemented the programme would fund basic health care through insurance premiums and various taxes. Children, pregnant/lactating women and the destitute – to be determined by communities – would be exempt from premiums, Kabia said.

A December paper outlining health policy options, by the national social security agency and the International Labour Organization (ILO), said the proposal “has tried to incorporate the positive aspects of different financing modes in a single and comprehensive scheme”.

There is debate among health experts over the best way for governments of low-income countries to provide quality health care to all, with most NGOs calling for the elimination of all user fees.

Sierra Leone already has a policy in place whereby children and pregnant women are to receive free health care: The fact that the country has been unable to implement it points to the challenges of financing the health sector. The obstacles are all the greater in countries like Sierra Leone which is rebuilding from a decade of war.

“Informal” fees

Services for under-five children and pregnant women are still subject to “informal” fees at health centres, in large part because state medical workers are paid poorly or not at all.

“We have to provide incentives so health workers do not have to [require] informal fees,” Health Minister Kabia said. “They are not paid sufficiently to be able to take care of their families.”

Health NGOs and donors in the country say whatever route the government decides for financing health care, much needs to be done to develop the health infrastructure, and immediate steps must be taken to ensure that children and pregnant women receive free care.

The UK’s Department for International Development (DFID) has pledged it would financially back the government in ensuring free care for these groups, according to Joanna Reid, deputy head of the DFID office in Sierra Leone and senior regional health adviser in West Africa.

Insurance

The eventual insurance scheme would be run by the existing National Social Security and Insurance Trust (NASSIT). “NASSIT already exists, so we would not be starting from scratch,” Health Minister Kabia said.

The new programme would call for "a total abolition of user fees”, according to the NASSIT/ILO paper, based on a 2008 study that included a review of other African countries that have national health insurance programmes. Financing would come from various taxes (including on alcohol and cigarettes), contributions from citizens (depending on their employment) and, initially, donors.

Kabia said the final plan would have to be approved by the cabinet and a law passed. The new health insurance programme would be phased in by district, and according to the NASSIT/ILO paper, a sustainable system would take 10 to 20 years to put in place.

The NASSIT/ILO paper says: “The consultants are well aware of the complexity of any such undertaking” and the development of this scheme should be “as open and participatory as possible.”

Advocates of fee removal say that while insurance schemes can play in important role in financing health care, they do not guarantee access for all.

“Insurance schemes have to be considered in relation to the contribution they make towards universal access (including for vulnerable groups),” according to a May paper by a group of NGOs including Oxfam, Save the Children UK and Plan International.

Johan Mast, head of mission for Médecins Sans Frontières in Sierra Leone, told IRIN: “For MSF, the most important thing is that whatever approach is selected, it has to provide free quality health care for the people of Sierra Leone, in particular children and pregnant women.”

MSF and Save the Children on 29 January hosted a roundtable that brought together representatives of the government, donors, NGOs and civil society among others to discuss how to improve access to quality health services.

IRIN