by Molly Warrington
After assuming office in 2007, Ernest Bai Koroma faced a country in distress. Just five years prior Sierra Leone had concluded a fierce 11-year civil war leaving the nation in shambles. The government was no longer capable of delivering basic services to its citizens and there was a vast need for repair in industries such as energy, agriculture, infrastructure and health. The president was faced with the task of deciding what to do about the extremely high maternal and child death rate in the country-which were the highest in the world at the time. There had already been failed attempts at providing free health care in the country so when Koroma announced his initiative to provide free health care to pregnant women, lactating mothers and children who were under the age of five, he faced skeptics who were unsure about his plan. Despite the opposition and criticism of the president’s ambitious plan and quick time frame to implement the policy, Koroma was able to implement the program in Sierra Leone. Many hurdles and obstacles were in the way of the plan and its success as well as important lessons learned throughout the process in regards to reforming the health institution in Sierra Leone.
Koroma, known for his previous work as an insurance broker, promised to run the country and government more like a business, focusing on the needs of ordinary citizens when he assumed office. At the forefront of his agenda was developing the second Poverty Reduction Strategy paper for the nation, which Koroma labeled as his personal “Agenda for Change”. This paper would outline the areas that needed reform within the government including, agriculture, infrastructure, health and other social services. After Amnesty International published a report citing the poor maternal and childcare in Sierra Leone as a human rights emergency, Koroma quickly poured his energy into implementing the Free Health Care Initiative (FHCI) in Sierra Leone.
The road to implementing FHCI was a bumpy one and Koroma knew that it would take strategic planning to reach the end goal. There was virtually no government capacity in place. Additionally, to make matters worse the health sector was facing issues such as low salaries, lack of medical supplies and few qualified staff to meet the needs of the patients. In order to make the initiative work many challenges needed to be faced and a clear plan needed to be put in place.
Koroma knew that he needed someone who could be his right hand throughout the entire process. Dr. Kisito Daoh would be that person for the president. Doah was a key player throughout the entire FHIC process, serving as the chief medical officer of the Ministry of Health and Sanitation Doah proved to be an invaluable leader and asset to the president. Other important players included the African Governance Initiative (AGI), Department for International Development (DFID), The World Bank, other ministries and agencies within the government in Sierra Leone and international NGO’s and aid organizations.
Key Lessons Learned
Need for a concrete plan to be in place
Prior to Koroma’s push for health care reform, there had been two failed attempts at it already. In 2002 there was an attempt by the health ministry to launch a free health care program but the ministry failed to do so because of their mistake of not taking into consideration the issues facing the health sector including low wages for professionals and a lack of supplies. Again in 2005, steps were taken toward reform by the elimination of user fees but the initiative failed because the government lacked the capacity to enforce the new laws. Medical professionals began charging informal fees on top of the price citizens had to pay for medicine that the government did not cover, thus discouraging citizens from utilizing the medical system .
Koroma knew that a clear plan needed to be put in place, which communicated a clear set of visions and goals for the initiative. The plan allowed for there to be concrete objectives written out that helped the ministry coordinate with the rest of the government and reach their goals. The plan Koroma put in place also helped the ministry coordinate with foreign donors and ensure that their money was being spent in the most effective way possible.
Committees and Coordination
Due to the lack of capacity within the government, Daoh and the vice president to Koroma recommended the use of committees to ensure success of the program. Technical committees were established to focus on minor issues and keep the action going while a larger steering committee was put in place to focus on major issues. Technical committees for areas in finance, drugs, infrastructure, human resource, logistics, communication and evaluation were put in place. The technical committees were particularly important because communication across different government agencies such as the Ministry of Finance, the Accountant General, Port Authority and Ministry of Works and Infrastructure was necessary for goals to be accomplished and the technical committees helped promote communication across the different government agencies.
The committees were particularly useful in enforcing the focus on the initiative that was laid out in the beginning of the project by Koroma. Committees ranked the importance of each task through the use of trackers. Trackers were simply spreadsheets that listed key priorities that needed to be completed, the level of each priority and which agency official responsible for each priority. Through this monitoring system tasks were accomplished on time and officials were able to hold one another accountable.
Regular committee meetings were also held to keep all parties involved up to speed and to address any issues committees may have faced in a timely manner. The regular meetings helped increase the governments capacity as well as promote more communication throughout all agencies and parties involved. Daoh and Koroma regularly attended the meetings and often held their own between the two of them to ensure they were on top of everything .
A strong health system needed to be in place
One of the main reasons why medical care was lacking in the first place was a result of the virtually nonexistent health system in Sierra Leone. Koroma and Daoh knew that this needed to change for the initiative to move foreword and be meaningful. Key elements of a health system needed to be in place such as a skilled staff, efficient internal structures to manage the staff and proper medicine and supplies to be utilized .
Collaboration with the Human Resources Office was imperative in order for the initiative to be properly staffed. The technical committee focused on human resources played a critical role in providing oversight ensuring that the proper doctor-to-population ratio was reached as well as ensuring that past employees no longer working for the government were removed from the payroll. Additionally, when the health workers went on strike Korma knew he had to directly confront them in order to ensure that the strike did not hinder the progress of the initiative.
Institutions need to be built to withstand shocks
When the Ebola crisis struck Sierra Leone progress made by the initiative was halted. The nations health institution was not resilient enough to fight the disease and as a result thousands of citizens died. Recently the WHO released a statement regarding the most recent outbreak of Ebola in Sierra Leone complimenting the nations efforts of battling and managing the outbreak . There is still room for improvement in terms of the government’s ability and capacity to fight Ebola and increase their resiliency to other threats to the health institution but the nation is moving in the right direction.
The success of the free health care initiative was dependent on the priorities placed on coordinating efforts amongst government agencies, putting proper structures in place and having an executive with a clear vision for the initiative. President Koroma and his team used a strategic and systematic approach to solving the health care crisis in Sierra Leone that turned out to be pretty successful. The case of Sierra Leone highlights the importance of communication and coordination in regards to building capacity in an institution that is lacking in that area and how through monitoring and evaluation goals can be reached.
Scharff, Michael. A Promise Kept: How Sierra Leone’s President Introduced Free Health Care In One Of Poorest Nations On Earth, 2009-201. Accessed 29 March 2017.
Taylor, Catherine H. Building Better Systems for Women and Children: Lessons on Universal Health Coverage from Sierra Leone. Global Health Impact Blog, 9 December 2016, https://www.msh.org/blog/2016/12/09/building-better-systems-for-women-and-children-lessons-on-universal-health-coverage. Accessed 29 March 2017.
Witter, Sophie. The Free Health Care Initiative in Sierra Leone: Six Years on Six Lessons. The Lancet Global Health Blog, 31 May 2016, http://globalhealth.thelancet.com/2016/05/31/free-health-care-initiative-sierra-leone-six-years-six-lessons. Accessed 29 March 2017.
World Health Organization. WHO on the end of Ebola flare-up in Sierra Leone. World Health Organization, 17 March 2016, http://www.who.int/mediacentre/news/statements/2016/end-flare-ebola-sierra-leone/en/. Accessed 29 March 2017.
 Scharff, Michael. A Promise Kept: How Sierra Leone’s President Introduced Free Health Care In One Of Poorest Nations On Earth, 2009-201. Accessed 29 March 2017. Case Study. Pg.3.
 Witter, Sophie. The Free Health Care Initiative in Sierra Leone: Six Years on Six Lessons. The Lancet Global Health Blog, 31 May 2016, http://globalhealth.thelancet.com/2016/05/31/free-health-care-initiative-sierra-leone-six-years-six-lessons. Accessed 29 March 2017.
 Scharff, Michael, pg. 3
 Scharff, Michael, pg. 7-8
 Taylor, Catherine H. Building Better Systems for Women and Children: Lessons on Universal Health Coverage from Sierra Leone. Global Health Impact Blog, 9 December 2016, https://www.msh.org/blog/2016/12/09/building-better-systems-for-women-and-children-lessons-on-universal-health-coverage. Accessed 29 March 2017.
 Scharff, Michael, pg. 10
 World Health Organization. WHO on the end of Ebola flare-up in Sierra Leone. World Health Organization, 17 March 2016, http://www.who.int/mediacentre/news/statements/2016/end-flare-ebola-sierra-leone/en/. Accessed 29 March 2017.