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One possible shortcoming worthy of note is that fact that, although the FHCI applies equally to all target groups irrespective of differences in poverty ranking, it may not be addressing vertical inequities. The FHCI is heavily dependent on donor funds, which covered 87 per cent of the cost of the effort in Substantial budget and donor investments - and the maintenance of donor enthusiasm - are needed over the next four years for successful implementation of the programme.

Poorly equipped health facilities, as well as untrained and unmotivated staff adversely affect the quality of health service provision. The number of health staff is still insufficient to meet the demand for service delivery although it has increased since the launch of the FHCI. Most health facilities do not have continuous water or electricity supply, and there are frequent break downs in the cold chain system.

Setting the context

Progress reporting has proved to be another hurdle to overcome during the first year of FHC implementation. It is crucial to be able to measure progress by delivering accurate data in order to maintain donor trust, maintain programme momentum and aid further planning.

Timely clearance of drugs and medical supplies has also been difficult at times, and transport delays frequently hamper distribution leading to stock-outs of vital drugs and supplies at the local health centers. In addition, there have been issues of transparency, leakages and thefts of drugs and nutritional supplements. Accountability needs to be improved at all levels.

Because the FHCI requires the collaboration of many players, oversight, coordination and management must be strengthened at all levels to ensure the efficiency, transparency and sustainability of this massive intervention.

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Removal of user fees has greatly enhanced health service delivery and increased uptake of basic health services leading to an appreciable increase in coverage through critical health interventions. The quality of health care must improve in tandem with increasing demand and access, otherwise some targeted beneficiaries may not utilize the service.

Therefore, the sustainability of resources and systems must be considered from the outset of planning.

Although the concept of free health care is not new globally, its adoption in practice resulted directly from the leadership and determination of the Government of Sierra Leone, which galvanized health system stakeholders to take action. The big challenge of leakages presented an opportunity for the development of a clear risk control matrix, fully endorsed and owned by Government, which can be used as a reference case for other countries.

The successful implementation of the FHCI in Sierra Leone and the lessons that have been learned provide a ready platform for understanding how to strengthen central and district level health care systems to deal with problems that cannot be tackled by PHUs. Modalities are being put in place to strengthen these levels. This initiative has also illustrated how political will, removal of user fees, and improvements in facilities, supplies and human resources can increase demand for, and use of, health care and other basic services to reduce inequities for women and children.

The FHCI has contributed to narrowing the geographic and socio-economic inequities in access to health care.


  1. Civil society contributions to pro-poor, health equity policies.
  2. Download Health Systems Confront Poverty (Public Health Case Studies).
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Maintaining success depends on the sustainable delivery of free health services and removing remaining bottlenecks so that more pregnant women, nursing mothers and children under five years of age can use the services. The FHCI initiative has also laid the groundwork for the development of a national health financing strategy that may eventually include a national social insurance scheme that can provide protection and care for all people in Sierra Leone.

Health systems confront poverty

Government needs long-term support from its partners to upgrade the entire health system. Strategies are being considered for mobilizing resources to finance health care systems both internally and externally and to strengthen public financial management procurement systems. The Ministry of Health and Sanitation will continue to strengthen training and capacity development of human resources to meet the need for more skilled health professionals. In view of this situation, the International Labour Office ILO and the Panamerican Health Organization PAHO , have decided to carry out a joint initiative to seek innovative ways to reach the excluded population and provide them with health care.

The Montefiore Health System in New York | The King's Fund

The meeting will produce guidelines for a five-year action plan. This "Action Plan for the Americas" will be a powerful instrument to mobilize national and international efforts in order to allow all men and women to have access to health services. The use of "micro-insurance", a community insurance system controlled by the community itself in terms of levels of contribution and benefits, has been proposed to reduce social exclusion.

A report on Micro-insurance experiences 3 presented to the meeting shows that Micro-insurance systems have contributed to improved health equity. The experiences of Colombia, the Dominican Republic, Ecuador, Nicaragua and Peru show that members of Micro-insurance systems have better access to health care, while the quality of care improved significantly. Chinery-Hesse in her address to the meeting. Ziglio, E.

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