Commentary
The ramifications of the just concluded British elections, which saw the defeat of the ruling Labour party and Prime Minister Gordon Brown’s decision to resign as leader of the party pose very serious potential developmental challenges in both the short and medium terms, for the Sierra Leone government and especially the recently rolled out 70 percent British government financed, socialized free health care initiative for pregnant women, breast-feeding mothers and children under five years together with other DIFD funded programs in the country.
This conclusion is borne from the fact that Gordon Brown and to a lesser extent his predecessor Tony Blair and the Labour party, largely and singlehandedly championed the ideological shift towards elimination of market based healthcare user fees, in favor of free foreign-aided healthcare, government managed and NGOs, mostly in underdeveloped countries, both in his capacity as the Chancellor of the Exchequer and later as Prime Minister.
Foreseeability of projected policy change
Since the policy and program priorities of the new Conservative government and its leadership may well be diametrically opposed to the funding programs embarked upon and commitments made by the Gordon Brown and Tony Blair-led Labour party, it is but prudent and reasonable to postulate that a resultant scaling back or outright cancellation of programs in countries such as Sierra Leone may be inevitable.
Historically, the policies of the Conservative party have been guided largely by jingoistic private enterprise free-market based solutions rather than the socialized aid- based approach of the Labour party to addressing issues of poverty and underdevelopment in third-world countries. Burdened with large deficits at home and an ideological bent towards the center- right in fiscal policies, Prime Minister David Cameron’s government may seek to reduce commitments overseas as it embarks on cost cutting programs at home to balance its own budget. It would therefore not be surprising to see the axe or substantial curtailment in continued funding of programs, such as the Sierra Leone government free health care initiative.
The Bamako Initiative vs. abolition of user-fees:
The period from independence until the introduction of the Bamako Initiative in 1987 largely saw the practice of government delivered, managed and funded virtual free healthcare, the model in Sierra Leone. The period also witnessed the introduction of "under-five clinics" throughout government hospitals and clinics where services were delivered free at government expense for pregnant women and children under five. Though subsequently poorly managed and succumbing to the vicissitudes of the creeping corruption permeating the nation and the failure to move away from total management by bureaucrats in the Ministry of Health and Sanitation of the health care infrastructure, this system finally succumbed in the 1970’s and 1980’s as governmental funding precipitously declined.
The Bamako Initiative was thus the culmination of efforts by African Ministers of Health in the 1980’s to stem the alarming deteriorating health indictors witnessed throughout the continent, by seeking to inject market-based financing mechanisms in the delivery of healthcare. The ministers signed the Bamako Agreement with the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF). This ideological shift in thinking on healthcare financing and delivery promoted the idea that getting patients, especially the economically able to pay for treatment and health services through user-fees would help bring in scarce healthcare resources, create a more sustainable delivery market- based model and increase efficiency.
Why Sierra Leone?
The genesis of Sierra Leone’s abolition of user-fees for maternal and child health services can be traced to the then Chancellor of the Exchequer, Gordon Brown’s declaration that "there must be universal and free schooling and healthcare as the beginning of justice for the poorest countries of the world". Subsequently as Prime Minister in 2009, Gordon Brown wrote to some of the poorest countries with user fees, including Sierra Leone offering British government support, both in aid and technical assistance, to those who wished to abolish the fees.
Sierra Leone a perennial foreign aid-dependant nation immediately jumped on the bandwagon and became on April 27, 2010 the first of the six countries, that had made a commitment in September 2009 to removing user fees for maternal and child health.
At a UN meeting in September 2009, Prime Minister Gordon Brown pledged to share the British expertise on creating free health services through a new ‘Centre for Progressive Health Financing’ which developing countries would be able to turn to for assistance. The establishment of this center in Britain with employment opportunities for British citizens and serving as the nerve center for NGO participation in Sierra Leone’s healthcare system, is the kicker for the continued reliance of countries who sign up for this so-called free health care to remain financially and politically dependant on the British government for their healthcare policies and an incubator for the socialized healthcare that even the British were rejecting.
It is thus not surprising that despite implementation of market based insurance or social insurance based medical healthcare systems and programs in western countries and the United Kingdom itself, Gordon Brown was seeking to sign up developing nations for programs his own society could not fathom or tolerate.
This new program, a part of the country’s six-year strategy to make healthcare free for all vulnerable groups, such as the elderly and the very poor by 2015 is projected to receive £34 million from the British government and is slated to provide free healthcare to about 230,000 women and one million children, as well as strengthening the healthcare system for the wider population.
Are free- user fees sustainable?
As a proponent of free markets and private enterprise solutions to most of Sierra Leone’s perennial underdevelopment problems, I have for several years articulated a market-based social insurance program that can effectively address the inefficiencies, funding and delivery problems in the healthcare system.
The continued dependence on the Ministry of Health and Sanitation for implementation of health delivery and financing programs is doomed to failure as evidenced from the historical data dating to independence.
As at roll out of the program on April 27, 2010 donor funding was not sufficiently predictable or sufficiently large enough to support reaching the program’s projected budget. Even if efforts to improve the effectiveness of current aid for health are successful, a sharp increase in resources is required. For example, the Sierra Leone government estimates the cost of delivering free maternal and child healthcare to be $91 million for 2010. By its own admission, there is still a $20.1 million shortfall in commitments as of November 2009.
An analysis of the program’s funding reveals that less than fifty percent (44 million dollars) of the budgeted 91 million dollars is for the provision of drugs and medical consumables. The remaining 47 million dollars budgeted is actually for such expenses as governance structures, human resources, communications and monitoring and evaluation.
The government’s total committed funding for this much touted free health care program is a paltry 12.5 million representing its total health budget for 2010. It is further note worthy that of the entire 12.5 million dollars health budget, the government’s allocation of 70 percent to the Reproductive Child Health program renders the remaining 30 percent for the entire country’s medical healthcare funding.
The unsustainablity of the free user fees policy, especially for Sierra Leoneans who can afford healthcare and the delayed implementation of a social health insurance system where employers, employees and government all participate renders this current approach of a government only managed system a false panacea to the inevitable looming disaster.
It is thus hoped that policymakers in the Sierra Leone government not only planned and projected for the ideological tendencies in British politics, as it embarked on the Gordon Brown- induced shift away from the "Bamako Initiative" in healthcare delivery and funding; but that it will now proactively seek alternative funding and social health insurance mechanisms and models to continue the healthcare reform initiative.
Innovative financing, revolving around new sources and new instruments for raising revenues from at least the financially able Sierra Leone middle class participating in the program, through a means- test outside of the tax revenue systems, must be pursued and implemented to include mechanisms that will incorporate various market-based aspects of financing – from additional user funding to the effective leveraging and use of the already pledged donor funds.
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