Evaluation of the Free Health Care Initiative (FHCI) in Sierra Leone
Introduced by the President of Sierra Leone in 2010, the Free Health Care Initiative (FHCI) abolished health user fees for pregnant women, lactating mothers and children under five years of age. This action was taken in response to very high mortality and morbidity levels among mothers and children in Sierra Leone – some of the worst in the world – and reports that financial costs were a major barrier to health service uptake and use by these groups.
Our report presents an independent review of the FHCI. DFID funded the study, which has been coordinated with the Ministry of Health in Sierra Leone and other key stakeholders. The findings of the review remain relevant not just in terms of assessing this important policy initiative retrospectively but also to inform the rollout of the current post-Ebola investments in Sierra Leone.
There are a number of important features of the intervention that influenced the design of the review:
• The FHCI was a complex intervention, involving not only changes to charging of the target groups but also actions to strengthen all health system pillars. The review is therefore of this whole package of health system reforms.
• The FHCI was implemented in a dynamic way, triggering and responding to changes over time. This review is therefore not based on a snapshot in time but is of an evolving story.
• The FHCI was a ‘whole system’ change, introduced in all regions simultaneously. This means there is thus no ‘control group’ to provide a counterfactual. No baseline was done and many data sources were only introduced after the FHCI – representing a major constraint to before/after assessments.
The study used a theory-based evaluation approach. A theory of change (ToC) was developed in 2014 by the evaluation team to map out how the FHCI might produce impact and what would need to be examined to understand whether it had done so and, if so, how and why. An evaluation framework was then developed to map possible information sources against each domain. We then drew on mixed methods to populate the framework, triangulating between sources where possible to come to judgements about the plausible contribution of the FHCI.
Analytical approaches included interrupted time series analysis of national survey data to examine mortality and morbidity trends and draw inferences about the contribution of the FHCI to observed trends, as well as modelling of impact using the Lives Saved Tool (LiST) and modelling of future revenues and expenditures for the fiscal space analysis. Other data sources include key informant interviews (KIIs) at national and district level, focus group discussions (FGDs) in four districts, extensive document review across all health system pillars, and analysis of routine information systems (for financial, staffing, logistics and health output data). The review also incorporated key findings from other relevant research projects, such as ReBUILD (for analysis of human resources (HR) and some health financing indicators).
Despite the difficulties with data and counterfactuals, we can say with confidence 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 some important systemic reforms. Underlying this achievement was strong political will, which has been sustained, enhanced donor cooperation, the deployment of supportive technical assistance, and consensus among stakeholders that the FHCI was significant and worth supporting. Weaknesses in implementation, however, have been evident in a number of core areas, such as drugs supply.
We are able to conclude with reasonable confidence that the FHCI was one important factor contributing to improvements in coverage and equity of coverage of essential services for mothers and children - though clearly Ebola in 2014/15 has played a major role in eroding previous gains.
At the outcome level, it is unclear from the data whether the FHCI contribution fed through into improved health for the target population overall, although there was a very sharp drop in under-five mortality associated with the start of the initiative.
More broadly, it is important that efforts are made to monitor and very likely improve the quality of care provided in public facilities. In addition, there needs to be continued efforts to overcome residual barriers, including lack of transport and socio-cultural barriers, to ensure gains are fairly distributed. On the supply side, efforts to improve the economy and efficiency of key resources – especially staffing and drugs – will be critical, as will addressing some of the harder-to-reach underlying systemic challenges, such as strengthening the MoHS and the devolved health functions at district level and improving public financial management. The sustainability of the FHCI is not assured without such a focus and increased public investment in health care in general. This requires the efforts of all stakeholders, including the development partners, to enhance performance and accountability in the sector.