The removal of user fees in Sierra Leone in April 2010 for pregnant women, lactating mothers and children under five, referred to as the FHCI, has attracted enormous political attention at the national and international level. The UK government provided financial, technical and political support to the FHCI throughout the preparation and implementation stages of the reform. Evaluating the impact of this support as well as the reform itself is therefore crucial.
The HEART/OPM team has been working on this review since April 2014. This final report presents all analysis undertaken, final conclusions and recommendations.
2.2
Background
The President of Sierra Leone introduced the FHCI for pregnant women, lactating mothers and children under five in April 2010. This targeted removal of user fees was supported by earlier evidence (MoHS, 2008) that showed health-related financial costs were a major deterrent to mothers and children using health services in Sierra Leone, a fact consistent with evidence at the international level.
Higher levels of utilisation of health service by mothers and children have been reported (MoHS, 2011; Maxmen, 2013) since the introduction of the FHCI. To date, the relationship between changes in the uptake of services and the FHCI has not yet been fully researched or evidenced. Moreover, whether the FHCI (and a series of supporting health systems strengthening reforms) is translating into saved lives and improved health outcomes among mothers, newborns and children has yet to be assessed. This review is meant to fill this knowledge gap.
2.2.1
What is free health care in Sierra Leone?
As was noted above, the FHCI was launched in April 2010 by the President of Sierra Leone in response to high maternal and child mortality rates, which were among the worst in the world. The programme aimed to make health services free at the point of delivery for the target populations of expectant and lactating mothers and children under five years of age. It aimed to treat up to
230,000 pregnant women, 230,000 lactating women and 1 million children under five every year, saving lives and improving health outcomes (GoSL, 2009a).
The programme was complemented by seven ‘supply-side’ interventions intended to strengthen health services in order to meet the additional demand created (see Box 1).
Box 1: The FHCI and its seven supporting health system interventions
Drugs and medical supplies: The continuous availability of equipment, drugs, and other essential commodities;
Health workforce: Adequate number of qualified health workers;
Governance: Strengthened and effective oversight and management arrangements; Infrastructure: Adequate infrastructure to deliver services;
Communication with the general public: More and better information, education and communication to stimulate demand for free high-quality health services;
M&E: A comprehensive M&E system;
Financing: Sufficient funds to finance the FHCI.
In sum, the FHCI constitutes a package of interventions, namely user fee removal (the core intervention) augmented by seven2 supporting intervention areas that seek to strengthen vital
areas of the health system’s function and delivery.
Two features of the FHCI in Sierra Leone are particularly important to note:
First, from the outset a more comprehensive approach was taken to realising it, i.e. not just
focusing on announcing the end of charging at the point of use (as had happened in some
countries of the region) but also working from an early stage on some of the health system support measures that would be required to respond to greater patient demand, and thereby deliver
results. The fact that the FHCI was a more comprehensive approach implies a degree of foresight and innovation that may influence results. Health system strengthening efforts illustrated via activities undertaken in the ‘seven pillar’ areas will be examined to assess how the various components work together, and whether this systemic approach is effective and illustrates important explanatory variables that influence the attainment of results. Moreover, findings and lessons from the FHCI will be compared and contrasted to user fee removal experiences in other countries, including where hand-in-hand efforts to strengthen health service supply have been less forthcoming.
Second, unlike the cases of some other free health care reforms in the region and, indeed,
previous reform attempts in Sierra Leone,3 the FHCI was able to capitalise on donor support and
assistance, reinforcing political will. The combination of these two factors has led to the FHCI catalysing a rolling programme of reform. This has substantial implications for the evaluation: in this case, what is being evaluated is not a one-off change but rather a rolling series of health system reforms. These can then be linked to changes in outputs and outcomes – as a package – rather than as individual actions. Using a contribution analysis approach, factors driving the process and barriers/facilitators have been identified from the chronology and tracked (2010– 2015), with findings corroborated or triangulated against other available relevant data sources.
2.3
The evaluation questions
Assessing the impact of the FHCI has been defined as answering, to the extent possible, the following evaluation questions:
What contributions to health outcomes, among the target groups, did the FHCI make and how were these achieved?
2 Although the original MoHS policy reform papers talk about ‘six pillars’, there were in effect seven working groups created, including financing.
3 There was an attempt to eliminate user fees in Sierra Leone in 2005, which failed because the government could not enforce the law and informal fees replaced formal ones (Scharff, 2012).
Does the FHCI represent VfM generally, and specifically in terms of disability-adjusted life years (DALYs), lives saved/deaths averted, and illnesses treated?
How and to what extent were the six priority interventions that were put in place effective in enabling the FHCI to be operationalised?
Are the six priority interventions the right ones to ensure continued and increased utilisation of services by the target beneficiaries?
What are the socio-cultural issues that affect the uptake of free health care among the target beneficiaries?
Did the FHCI have a differential impact on different socioeconomic groups or marginalised groups?
Were there any unintended consequences of the FHCI?
To do this, research methods and study designs were developed in 2013/14 and further refined based on observed data quality and availability.
2.4
Research methods
The research methods have been described at length in the inception report. However, some amendments to the original methodology proposed have become necessary, for example as a result of lack of data or poor quality data.
2.4.1
The ToC for the FHCI
The intention of the FHCI is clear. Health-related financial costs have been identified by target groups as a major reason for suboptimal use of health services; therefore, providing free health care to these target groups should increase their access to health care, which in turn is expected to reduce morbidity and mortality. This logic underpins the ToC driving this evaluation.
Figure 1 illustrates the ToC that has been used to review the FHCI as a whole. The FHCI results pathway (i.e. the middle column) illustrates relationships and progression in a linear manner. Of course, the health system is not a simple linear process and often different aspects of ‘outputs’ and ‘outcome’ can be circular over time, which is recognised implicitly by the framework. The FHCI is identified through the funding at input level and the increased patient throughput at output level. The package of seven complementary interventions is identified in terms of their implementation at process level and results at output level. The health system pillars are unpacked in more detail in the evaluation matrix (see Annex B). The overall impact is taken to be the saving of lives of mothers and children, across all income groups but especially the poor, together with both the reality and perception that the policy is appropriate and fair to all. Factors identified as part of the ‘policy process and drivers’ in Figure 1 are considered ingredients that vitally support and drive results attainment. To the contrary, other factors identified as ‘risks’ will inhibit or block results attainment. The action of these ‘push/pull’ factors will be closely examined over the duration of the evaluation because they are key explanatory variables that define the operating context within which the FHCI is being implemented, and the extent to which results are achieved. It is also important to consider other explanations (beyond the FHCI) that may also account for observed ‘impacts’.
Figure 1: Evaluation ToC
Policy process and drivers
Wholehearted ownership and engagement by health service staff and
communities
Effective accountability mechanisms developed, including civil society
Effective governance and management that actively responds to problems identified by M&E systems
Effective GoSL/donor partnership
Capacity building
Impact (Consider other explanatory factors / rival explanations, e.g. socioeconomic factors, other interventions, etc.) • Save lives of mothers and children
• Reduced poverty and health inequality in target groups • Strengthened social cohesion (perceptions of policy fairness)
Outcome
• Reduced barriers to uptake
• Increased service coverage and utilisation by target groups • Better health/reduced morbidity
• Improved quality of care and referral system • VfM and cost-effectiveness – actual and perceived
Outputs
• Improved and strengthened health system
• Increased patient willingness and ability to use the public health system, leading to higher throughput
• Adequate numbers of trained staff available • Adequate supply of drugs
• Adequate, functioning infrastructure
Process
• Effective implementation and scale-up of six supporting interventions/NHSSP ‘pillars’ (including finance)
• Increased community awareness of the FHCI and rights under the programme
• Inputs
• Political will
• New, sustained financial resources from both internal and external sources
• Technical assistance
Risks/inhibitors
Waning political will
Inadequate governance or oversight by MoHS
Quality of care is weak
Non-fee barriers to free health care prevent take- up
Funding for the FHCI diminishes or is interrupted
The FHCI is not ‘free’ at point of delivery
Corruption/system abuse
Introduction of the Free Health Care Initiative
In order to achieve the goals of the FHCI, the basic prerequisites are as follows:
1. The FHCI is being implemented: This means that health services are free at the point of use