By Alhassan Fouard Kanu, London, UK.
Some time last year, I wrote an article advocating for the removal of user-fees from our health care system in an attempt to primarily reduce the high levels of infant and maternal mortalities as well as improving the health and well-being of all; and hence bolster our economic development. I informed my readers at the time that, user-fees are donor-driven based on the argument that, the user fee would be an appropriate financing mechanisms because, they would be effective in raising additional funds for governments; efficient (by encouraging an efficient use of services) and equitable (in benefiting poor people disproportionately).There are, however, growing evidence showing that user fees reduce usage and this effect is most pronounced in the suppression of demand for health care by poor people. It has been also proved to be inequitable because, poor and vulnerable people have been affected most; both in terms of their reduced use of services and through being impoverished by the effects of high catastrophic health expenditures. In Sierra Leone, where health facilities are very few and located away from remote and poor communities, people who are impoverished face other economic barriers such as transport costs and the opportunity cost of being away from work. The combination of these indirect costs and user fees has often effectively excluded poor people from the formal health care system; and hence, paving way for the proliferation of quacks and the popularity of traditional and spiritual healers in the country.
I sincerely thank the Ernest Koroma-led APC administration and country’s donor partners for the laudable effort in providing-though not for the general populace as earlier advocated- free medical services for our most vulnerable populations: underfive children, pregnant and lactating mothers. This scheme will go a long way in improving our statistics on mortality rates in these populations, which have, for a long time, blighted the image of the country. The successful implementation of this scheme should be the responsibility of every Sierra Leonean at home and abroad. Our children have the right to life; it should not be suicidal for our women to get pregnant. I, therefore, would want to ask all to give their support at all fronts to this scheme for its success and sustainability.
I suppose there is a growing suspicion though, from cynics as to whether this scheme is not another political gimmick with regards its sustainability. Yes, critical minds should come to play as we have seen the Free Education Scheme in primary schools failed woefully and ended up bleeding poor parents and/or preventing children from poorer families from schooling because of the informal charges levied by school authorities.
I, as a former frontline health worker, would want to share some of the experiences, the grumbles and gnarls from fellow colleagues who were operating in NGO supported clinics during the emergency/relief period of the civil war .Most of the NGOs were providing almost free treatments for adults and vulnerable groups, akin to the proposed scheme. The health workers were never bedfellows with these NGOs. Some doctors frowned on the idea of MSF providing free surgical operations in their hospitals; and Community Health Workers failed to cooperate with NGOs supporting their clinics, as they see their continued operations in those clinics as a threat to their livelihoods.
So the introduction of this scheme come April 27, would see heighten tension between communities and health workers, who would find it hard to detach from the ingrained practice of charging patients and monies go directly into their pockets. There is no doubt that, they would try to undermine the scheme by employing different approaches: under-treating patients, siphoning drugs off to their private pharmacies or selling them to drug retailers, introducing informal charges, giving a lacklustre performance to the job etc. Whilst it is clear that these are all corrupt practices, it equally begs the question on how you think a MCH nurse, whose clinic attendant is largely made up of the exempted groups (mothers and underfives children), could survive without the usual charges? Why a doctor should not ask for a consultation fee when lawyers, the police, and the politicians do ask for “hand-shakes”? Very soon, communities will be empowered to police this scheme, and dedicated health workers will be threatened and molested following its introduction.
I have spoken to some colleagues back in Sierra Leone lately about the proposed scheme. Many see it as a threat to their survival. Some are considering going into private practice or travel abroad, as they consider the scheme as a killer-blow should their condition of service remain the same. One remarked: “how could the government expect me to feed and educate my children on my current salary?”; another asked, “was it Ernest Koroma that paid my fees and how does he expect me to live?”. Whilst others may adjudge health workers as selfish and care only for themselves, I would hasten to say that, the much preached “Attitudinal Change” should, in tandem, focus on raising people’s standard of living. How do you expect someone to divorce bribery when it is the country’s password to survival on the current derisive salaries?
Let the government be aware that, the introduction of this scheme will surely overwhelm the understaffed clinics; meaning more jobs for these poorly-paid staff. So if the government is serious about, not only the introduction of the scheme, but also its sustainability, it should, by April 27, ensure that health workers salaries be upped, commensurate to the workload, and clinics be further staffed to meet the expectation of communities. Where this is not done, the health workforce can undermine the scheme in many ways; and poor families will have to recourse to their spiritual/ traditional healers with dire consequences on the health of our women and children.
Pivotal to the success and sustainability of efforts to provide an affordable and universal health care for Sierra Leoneans is a battery of competent and equitably distributed health workforce nationwide. It is therefore prudent that policies be directed in providing free training, especially for the frontline health workers (CHOs and Community Health Nurses/MCH Aides) who provide services to over 60% of the country’s population. This will not only help in increasing our health work force, but also will give the government the muscles to control the movement of its health professionals to private practice or migrating abroad.
Alhassan Fouard Kanu(photo) is a Community Health Officer (CHO) and currently studying in London, United Kingdom.
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