February 17, 2015 By Ibrahim Tarawallie
“I was expecting 100% service delivery from the health workers but that is not what happened. I [was unable to access] the free medication…I was asked to pay for drugs which are supposed to be free. I have also been hearing reports of health workers stealing drugs and putting them to their personal use.” Hawa Kamara of Wellington, Freetown, a beneficiary of the Free Healthcare Initiative (FHI), is far from happy with the running of this government program. FHI was rolled out across the country in 2010, and aimed to ensure that all government hospitals and Peripheral Health Units (PHUs) offer free healthcare services for all pregnant women, new mothers and children under five.
Kamara is not the only person to raise serious concerns that the Free Healthcare Initiative is being undermined by the theft of medication, and by illegitimate demands for payment for drugs that should be provided for free. In its 2011 report “At a crossroads: Sierra Leone’s Free Healthcare Initiative”, Amnesty International revealed that many members of the public had reported being asked to pay for drugs that should have been given to them free of charge. Meanwhile, Juana Tom-Kargbo, the manager of Save the Children’s Every One Campaign in Sierra Leone, says that “stealing of drugs and late referrals of cases come up during some of our dialogue forums with community people.” A report released by Save the Children International in December 2014 also suggests that health workers in the Western Area Rural sell ‘free’ healthcare drugs to members of the public.
The implementation of the FHI has resulted in other challenges, such as the overcrowding of health centers. Since the FHI was put into place, Ruby Williams, Matron at Princess Christian Maternity Hospital, says that the number of patients who access the facility increased by more than 100%. “Sometimes patients deliver in the ward because the labor ward cannot accommodate all [of them]…the management is aware and we have time and again reported [about overcrowding] and we expect to have a building put up to ease the stress, but that is just a promise,” she says.
It is difficult to dispute that such overcrowding exists, when it is so visible. However, the issues of medication theft and payment for ‘free’ drugs remain much more contentious.
A bold new initiative
The FHI was launched on 27 April 2010 by President Ernest Bai Koroma. The main objective of the Initiative is to bring down Sierra Leone’s high maternal, infant and child mortality rates, to work towards the achievement of the Millennium Development Goals. Initially, 20 types of essential drugs were dispensed through the FHI, but that this number has increased to over 30 with the inclusion of medication for family planning and reproductive health issues.
Jack Lansana, the Deputy Director of Drugs and Medical Supplies in the Ministry of Health and Sanitation, was unable to provide a figure for the total value of drugs supplied for free under the FHI since 2010, but disclosed that the government has already procured US$10 million worth of medication to be distributed in 2015.
The introduction of the FHI had been widely welcomed. Juana Tom-Kargbo says that before its launch, Save the Children had been doing a lot of advocacy work for new mothers, pregnant women and children under five, against the user fees that prevented many from accessing healthcare facilities: “the launch of the FHI was cause for much joy”.
Dr. Alimamy Philip Koroma, the Medical Superintendent at Princess Christian Maternity Hospital (PCMH) in Freetown, states that the FHI has resulted in an increase in the number of patients that visit this hospital. He says there has also been an increase in the number of safe deliveries per month. According to Sheriff Bangura, a pharmacist attached to PCMH, the hospital now has more than 90% of the drugs that are requested, and there has been a general improvement in the distribution of drugs in Sierra Leone, especially in the Western Area (Urban and Rural).
How is the flow of medication monitored?
Up until the end of 2014, the distribution of free medication was monitored by the United Nations Children Fund (UNICEF). The National Pharmaceuticals Procurement Unit (NPPU) in the Ministry of Health and Sanitation is due to lead a replacement monitoring process, but this has yet to begin.
This leaves two civil society organizations (CSOs) as the only entities currently providing a monitoring service for drugs distribution throughout the country. The first of these organizations, Health Alert, did not wish to provide comment for this story when approached by the Concord Times.
The second CSO undertaking an independent monitoring process is the Health For All Coalition (HFAC), the general mission of which is to advocate for the delivery of quality healthcare services to patients. Following the introduction of the Free Healthcare Initiative, HFAC partnered with the United Nations Population Fund (UNFPA) to provide increased accountability on the use of health commodities through undertaking monitoring processes.
HFAC trains monitors to conduct regular visits to health facilities across the country, especially those dispensing free medication. It monitors the distribution of FHI drugs from the Central Medical Stores in Freetown, where the medication is packed for dissemination to districts all over Sierra Leone. When the drugs arrive at the district level Peripheral Health Units (PHUs), the monitors verify that the quantities arriving tally with the quantities that left the medical stores. They also take inventories at community level, and share these with stakeholders including the Ministry of Health and UNFPA.
Alhassan Bakarr Kamara, Program Manager at HFAC, was ready to speak with the Concord Times about the monitoring scheme. He says that HFAC strengthened its monitoring systems two years ago, with the aim of ensuring that every Sierra Leonean who qualifies can benefit from the free medication guaranteed under the FHI. “To ensure there are no leakages in the supply of free healthcare drugs is … top of our agenda. We decided to expand our monitors in the communities … two years back, we had 201 monitors but we now have 300 monitors countrywide.”
Is medication disappearing, and if so, where to?
So what does Kamara think of the allegations that the Free Healthcare Initiative has been seriously compromised by the disappearance of large quantities of free medication? He initially emphasizes that, although there have previously been leakages at the Central Medical Stores, there were none throughout 2014. Here he is in agreement with Jack Lansana of the Ministry of Health and Sanitation, who attributes an eradication of theft at central level to the use of a new software system, the ‘Channel’, via which the Ministry supplies drugs to hospitals and Peripheral Health Units (PHUs) across the country on a quarterly basis. The system came into effect in 2014.
However, Kamara goes on to say that HFAC does indeed receive reports of free drugs being stolen by healthcare workers, even if the number of such reports has been reduced by the monitoring measures put in place. “We have reported to the authorities concern with regards to stolen drugs, especially at the Peripheral Health Units (PHUs) in communities by some unscrupulous health workers. Largely, theft of free medication drugs takes place in the facilities, but our worry is that the government reacts slowly to our reports.”
“Health workers in those facilities are responsible for recording the quantity of drugs they use against what is inside the store, but in most instances they [do not tally with the amount of medication delivered to the facilities]. We also have incidences wherein health workers fail to record. Large amounts of the free drugs are not accounted for at the PHU level,” notes Kamara.
Even Jack Lansana, the Deputy Director of Drugs and Medical Supplies in the Ministry of Health and Sanitation, admits that the theft of drugs does take place at community level. But he protests that this only occurs on a small scale. The UNPFA’s Communications Associate, Crispin Cole, argues that the monitoring being carried out by HFAC is achieving considerable success in acting as a deterrent against corruption. “As a result, there has been a substantial reduction in pilferage, and accountability in the use of health commodities has been strengthened,” he argues.
This is a point of view also endorsed by some beneficiaries of the free healthcare project who spoke to the Concord Times as part of this investigation. Fatima Sesay of Wellington says that she has benefited greatly from the FHI since it was launched in 2010, and has not encountered any tales of drugs theft. “Anytime I go to the hospital, the nurses and the health workers do give me the timely attention without any comment…I must confess that I have never heard of any report that drugs are being stolen by health workers,” she noted.
Paying for ‘free’ drugs?
The other alleged major shortcoming of the Free Healthcare Initiative is that some end users are being asked to pay for healthcare drugs and services that should be free. There is plenty of survey and anecdotal evidence to support this contention, both from CSOs such as the Health For All Coalition (HFAC) and from members of the public who have been supplied with medication.
HFAC, one of the CSOs that monitor the distribution of the free medication, says that in 2014 17% of beneficiaries reported that they paid for drugs or services that should have been free. “We pass the information to the authorities but no action has been taken. We continue to see an increase in this [trend]. We need to strengthen the system for those going into healthcare facilities to access medical services.”
A report published by Save The Children in December 2014 stated that at Sussex health facility, nurses sell contraceptives to teenagers that should be freely distributed under the FHI, and that pregnant women are asked to pay for the treatment and delivery they receive in the facility, which again should not be charged for under the provisions of the FHI.
Anecdotal evidence backs up the findings of this report. Ruby Williams, Matron at Princess Christian Maternity Hospital, says that in her own experience, payment for drugs that should be free under the FHI does indeed occur within the Sierra Leone healthcare system. “Unfortunately for me when those incidences [requests for payment for free drugs] do occur, people are afraid to report the matter to me. It is not easy to get hold of those nurses that are engaged in this act, but if we have evidence … we know what measures to take,” she said.
There are many more stories similar to this one. Even the Concord Times’ own reporter can give anecdotal evidence of a friend who has been asked to pay for ‘free’ drugs during pregnancy.
Yet some remain unconvinced. Dr. Alimamy Philip Koroma, the Medical Superintendent at Princess Christian Maternity Hospital (PCMH), denies that health workers would be motivated either to steal drugs or to sell free drugs, as the incomes provided to health workers are adequate. “The salaries of health workers, especially nurses, have improved, and let me say that if any beneficiary has evidence of a health worker requesting money for drug or service, let that person report to me and the individual will be dealt with according to the law.”