THE Sierra Leone Health Financing Conundrum: How to unlock the Huge Out-of- Pocket Expenditures by C

Successive governments of Sierra Leone have consistently shifted the burden of healthcare financing on to their citizens, albeit in a totally ad hoc manner, by placing the burden of financial risk protection mostly on households through out-of-pocket medical spending.

According to Dr. Luis Gomes Sambo, the WHO/Africa Regional Director, "an examination of the health financing situation in Africa reveals that countries will need to increase their investment in health and remove financial barriers to accessing healthcare through a number of innovative approaches, including compulsory prepayment and risk pooling mechanisms".  

Dr. Sambo further maintains that "improving health financing in the region will require several actions: the development of comprehensive health financing policies, plans and strategies and a move towards universal health coverage (UHC)".

Sierra Leone however has failed to implement any health financing strategy that could move the entire nation towards universal health coverage. This can be seen from the priority areas highlighted in her national health sector strategic plan 2010-2015, viz: to move progressively towards universal coverage for mothers and infants; to reduce the burden of communicable and non communicable diseases and to improve the quality of services.

The World Health Organization (WHO) health financing strategy provides for countries to develop suitable and equitable health financing systems, capable of supporting provision of quality healthcare services. This strategy requires the minimization of out-of-pocket payments by sick patients at point of service- a practice that has been shown to adversely impact access to healthcare services, especially by the poor.

A review of some WHO healthcare statistics on Sierra Leone glaringly shows the need to harness our already high out-of-pocket expenditures into some form of pre-payment national social health insurance scheme. Adoption therefore of a social insurance approach to healthcare financing in Sierra Leone offers several advantages, including universal coverage, protection against catastrophic out- of-pocket costs, broad public support, the ability to develop a more balanced delivery system and a reduction of the current two-class system of care. Why this has not yet been accomplished over the years, and especially after national validation of the ILO/NASSIT national health insurance report in 2009, represents a callous and deliberate effort and ploy by policymakers, aiding and abating the impoverishment of our compatriots.

OUT-OF-POCKET EXPENDITURES:

According to recent WHO figures and rankings, out –of-pocket expenditures as a percentage of total health expenditure in Sierra Leone in 2011 stood at seventy five percent. Between 1995, when Sierra Leone recorded an astronomical eighty one percent to the seventy five percent in 2011, the country has recorded consistently the highest out-of-pocket expenditure rates for healthcare by citizens in all of Africa.

The very high levels of out-of-pocket expenditures on healthcare services, including medications in Sierra Leone, has a direct corollary and debilitating impact on the level of impoverishment and standard of living in the country.  This burden is most acute among the poor who represent the most vulnerable and most at risk for catastrophic health expenditures.

GOVERNMENT HEALTH EXPENDITURES:

Through utilization of predictive analytics and data mining of health statistics, I have tried to juxtapose governmental health expenditures for the following baseline periods, viz 2007 and 2011.  Data from these periods incidentally neatly coincide with the periods of governance by the two main political parties, namely the SLPP and the current APC government.

In 2007 Sierra Leone spent 7.8 percent of total government expenditures on healthcare, with 31.3 percent of the 7.8 percent government spending, coming from external resources and 68.7 percent from private expenditures. Out-of-pocket expenditures as a percentage of the private expenditures on health in 2007 stood at 58.8 percent. Per capita government expenditure on health in 2007 was a measly 10 percent.

In comparison with her neighbors in 2007, the per capita total expenditure on health in Sierra Leone was 32 percent, while Liberia expended 39 percent and Guinea spent 62 percent on healthcare.

As a percentage of GDP, Sierra Leone's total expenditure on health in 2007 was a mere 4.4 percent, according to WHO reporting statistics. The general government expenditure on health, as a percentage of total expenditure on health in Sierra Leone represented 31.3 percent in 2007.

Leaping forward to the year 2011, general government health expenditure as a percentage of GDP stood at a mere 3.4 percent. This represented a growth rate of minus 20.5 percent for the period 1995 to 2011.

Moreover, the general government health expenditure per capita in Sierra Leone in 2011 was 30 percent.  The general government health expenditure as a percent of general government expenditures in 2011 stood at 11.7 percent, a decrease from the 14.2 percent recorded in 1995.

As a percentage of total health expenditures, the government of Sierra Leone expended 18 percent in 2011. External resources on health as a percentage of total health expenditure in Sierra Leone, was 19.9 percent - an increase from the 1.1 percent in 1995. As of 2011, the total out-of-pocket expenditure as a percentage of health expenditures in Sierra Leone is recorded at seventy five percent.

CONSTRAINTS:

As I have previously maintained the main source of constraint on implementation of a national social health insurance scheme or universal coverage is lack of governmental will and purpose.  

CATASTROPHIC HEALTH EXPENDITURES:

The mitigation of catastrophic health expenditures remains a major goal for universal health coverage worldwide. As my recent experience with sickness and hospitalization during a brief visit to Sierra Leone can attest, thousands of people confronted with the type of sickness and costs involved would have certainly had to make some very difficult hard choices.

As I lay in the ICU with several doctors and nurses surrounding my bedside, attempting to bring back my pulse and low blood pressure, draped with drips, oxygen tanks and other life saving paraphernalia, I could not help but wonder how the common man in Sierra Leone could afford such care. All prescription medications, diagnostic tests, room and board, attending physicians and consulting specialist physician services were required to be paid for prior to any of these services being provided or initiated on me. This included even the hospital meals and water.

In countries such as Sierra Leone without universal health coverage (UHC), families would have been forced to sell priced assets, be deprived of basic needs or resort to usurious money lenders to secure such medical care for their loved ones. In such a scenario, healthcare costs become catastrophic, causing ruin for families, which thus leads to them forgoing the care.

According to Sania Nishtar, in her blog the human side of catastrophic health expenditures, "every year one billion people do not receive services they need and 150 million individuals risk financial ruin when accessing care. Universal health coverage is not just a technical solution in the health sector but a nation's promise to its people".

Finally, since the basic premise of social insurance requires that under the auspices of the government, people are empowered and enabled to pool their risks for such costly events as medical care, it is hoped that the Sierra Leone government can be brought to understand that universal health is a human right and offers the most efficient manner of unlocking the burden of high out-of-pocket medical expenditures the people continue to bear.