The government of Sierra Leone has announced that from Independence Day (27 April) it will abolish user fees for pregnant women, lactating mothers and children under five, but will this, on its own, improve their lot?
IRIN looks at Sierra Leone for the third part of its series on maternal and child health.
Sierra Leone has the world’s highest maternal mortality rate - 1,800 women die per 100,000 live births, according to UN Children’s Fund (UNICEF).
C.T.H. Bell, a gynaecologist with the privately owned New Life hospital in Sierra Leone’s capital, Freetown, says that more critical than free treatment is speed of decision-making in the home, an efficient transport infrastructure, and prompt treatment on arrival at a health centre.
He suggested that the expansion of free health required more preparation, and should not be seen as a cure-all. “Have we put our house in order before inviting the guests? Women will go for free treatment - where? You are inviting people to your house, but do you have the drugs? Do you have the IV [intravenous] fluids you need? Do you have blood? Are your staff motivated?”
Abolishing user fees will not address life-threatening delays in delivering maternal care - even in the woman’s own community, he said.
“At times, the husband - who has to decide - is not there. Or maybe the mother will say: ‘No, let’s wait. Or maybe there is an old woman in the community who will say: ‘Wait, wait, wait’ - until it is too late,” Bell told IRIN.
Monir Islam, head of WHO’s Making Pregnancies Safer Programme, told IRIN poor roads and a lack of ambulances made it hard for people from rural areas to get to a city for emergency care. “Free care means little on its own. If women cannot make it to a centre, what good is free care?”
Traffic jams further slow down those trying to reach Sierra Leone’s only hospital handling obstetric and gynaecological emergencies, in east Freetown, said Bell. “If somebody has an emergency in the west, that person has to drive through the city to the east… By the time the person gets to the hospital, maybe [the woman or baby] is dead.”
Bell said there were often delays at clinics. “The patient… gets to the facility - no doctor, no nurse, no medicine, no blood and the patient has to wait until a doctor is called on duty.”
He said poorly paid public servants - the average monthly doctor’s salary is around US$100, while a 50kg sack of rice costs $34 - are worn out because they do multiple jobs to survive.
In June 2008 NGOs operated more than half the country’s health facilities, according to the Health Ministry. There are almost as many international doctors employed by NGOs (50) as there are local doctors (60). Nursing graduates are only able to find temporary work, when someone resigns or dies, according to the UN Population Fund. Many emigrate to foreign countries in search of better jobs.
Lack of trained government healthcare workers is all too often an excuse by governments to delay improving maternal health care, WHO’s Islam told IRIN.
In addition to training more health workers, governments should provide existing workers with the equipment and power supplies they need to do their jobs, he said. “If a woman makes it to the clinic, will there be trained midwives, an electricity generator?”
“Unless there is a comprehensive overhaul and improvement of maternal health care, poor people will continue to get only poor options, whether user fees exist or not.”
No-cost medical care will do little to make pregnancies safer unless health centres are better equipped to serve expectant mothers, according to WHO.