Changes in household OOP expenditure for FHCI groups

The more nuanced impact question is therefore whether FHCI groups are paying significantly less for health care than they would have without the introduction of the FHCI.

Table30 shows descriptive statistics on consultation payment at government outpatient facilities for children under 5 and lactating mothers, again using data from SLIHS 2003/04 and 2011. The

proportion of FHCI groups paying for consultation in outpatient health facilities reduced between the survey years for all groups. However, a significant proportion were still paying in 2011 for services that should have been free—particularly lactating mothers. In addition, of those who paid, the amount paid only reduced marginally in real terms for children under 5 and lactating mothers and increased for pregnant women. Mindful of data limitations, it appears that there is a bigger improvement for children under 5, than either pregnant women, who saw an increase in

expenditure for those who did pay (although a substantial reduction in those who paid in the first place) or lactating mothers, who saw a smaller reduction in those who paid.

Table 30: Out of pocket payments (OOP) for FHCI groups, 2003/04 and 2011

Under 5s Pregnant women Lactating mothers 2003/04 2011 2003/04 2011 2003/03 2011

Proportion who utilised a

government health facility in the last two weeks (if sick)

Estimate 64.4 74.8 71.7 80.2 65.6 75.5

N 1638 1580 276 150 287 105

Of those, proportion who paid for

consultation Estimate 76 20.2 79.7 41.7 65.9 50.6 N 1028 1183 196 118 177 76 Of those, average amount paid (2011 USD) Estimate 3.1 2.8 5.2 14.2 3.2 2.9 N 775 227 152 51 120 39

Source: 2003/04 and 2011 SLIHS

Data from other surveys and research do not find the same high proportions of FHCI groups paying as SLIHS, but still consistently shows that a small proportion of FHCI groups are still being charged. For example, Table 31 shows Health for All Coalition (HFAC) monitoring data for one quarter in 2012 and two quarters in 2014. Around 5% or fewer of FHCI groups sampled at the health facility had been asked to pay for drugs or treatment, with under 5 and lactating mothers who were paying for consultation in 2012 paying similar average amounts found in the 2011 SLIHS. The small sample sizes for average amount paid make it difficult to draw firm conclusions here, however, for example about any trends over time. Although any amount of payment is not ideal, given the known implementation issues, this level is relatively low.

That said, the Cordaid verification study of 2014 found that 12% of the target groups had made some payment. The average payment was SLL 7,881, ranging between SLL 200 and SLL 50,000. These payments were either for general consultations, MNCH services, medicines or the medical equipment needed to provide the care. There was found to be significant variations in the

proportion of patients asked for payments between the different local councils. None of the patients in Bonthe Municipal Council or Makeni City Council were asked for payments, but 52% of those in Kailahun District Council, 35% in Koidu New Sembehun City Council and 22% in Kono District Council were asked to pay.

Table 31: HFAC monitoring data on payment by FHCI groups, all districts Jun–Aug 2012 Mar–May 2014 Jun–Aug 2014 Children under five

Proportion who paid for drugs Estimate 1% 4% 3%

N 1385 1740 1921

Average amount paid for drugs Estimate 2.2 1.9 1.8

N 16 54 40

Proportion who paid for treatment Estimate 3% 4% 4%

N 1384 1730 1920

Average amount paid for treatment Estimate 2.3 4.5 5.2

N 36 72 40

Pregnant women

Proportion who paid for drugs Estimate 2% 5% 4%

N 942 1315 1497

Average amount paid for drugs Estimate 3.1 1.6 1.3

N 23 58 55

Proportion who paid for treatment Estimate 4% 4% 5%

N 942 1309 1493

Average amount paid for treatment Estimate 3.0 5.5 3.8

N 33 34 21

Lactating mothers

Proportion who paid for drugs Estimate 5% 5% 6%

N 111 690 897

Average amount paid for drugs Estimate 2.4 1.9 1.6

N 6 35 49

Proportion who paid for treatment Estimate 5% 5% 6%

N 111 686 896

Average amount paid for treatment Estimate 3.0 4.9 5.2

N 5 32 28

Source: HFAC monitoring data, 2012 and 2014 reports

However, these descriptive statistics still do not tell us the extent to which the FHCI contributed to these apparent reductions in chance of payment and amount of payment by FHCI groups.) Edoka et al. (2015) attempt to estimate the effect of the FHCI on OOP expenditure for children under five using impact evaluation techniques and find no statistically significant impact on OOP expenditure for children under five. This is in contrast to what we see in the descriptive statistics and suggests that there may be other factors at play in the reduction in payment for health care for children under 5. However, Edoka et al.’s study does assume that children just over five, because they are in principle not eligible for free health care, are a good control group for children just under five, who are. In reality, the policy was fuzzily implemented such that some children under five paid for health care and some children over five did not. The impact on OOP expenditure for pregnant women and lactating mothers could not be tested due to the lack of a credible control group.

In summary, the best available data show a modest reduction in real OOP expenditure from 2003/04 to 2011. Data from various sources suggest that chance of payment and amount of payment has reduced for FHCI groups, although evidence also consistently shows that a small minority of those in FHCI groups are still paying for health care. The attribution of any of these changes to the FHCI is not possible. Much of the analysis of household expenditure here and elsewhere (e.g. in the NHA and Edoka et al.’s studies) relies on data from the SLIHS, which is problematic for a number of reasons.

The community research we undertook supports the finding that free care at the point of use for the target groups is not always applied as intended, especially in Western Area and in towns. Moreover, this finding is also reinforced by the household life history interviews conducted by ReBUILD (Amara et al., 2016).

Even though FGD participants were all aware that services under the FHCI were meant to be free for children under five, pregnant women and lactating mothers, about half of them across the four districts mentioned that FHCI beneficiaries continue to pay for health services or provide other non-monetary items to some health care professionals. Such views regarding payments and non- monetary ‘gifts’ were more prevalent among participants from Western Area.

Participants shared that even though payments may not be required for the direct services, they were being charged other fees for registration cards and entrance fees:

“For me the only free services are ITNs and malaria drugs. I bought a registration card for SLL 2,000. When I gave birth, I paid SLL 5,000 for the nurses to see me. I received free ITN and malaria treatment” (Adult female, Bo).

Participants from Bo, Kono and Koinadugu were more likely than those in Western Area to mention FHCI beneficiaries receiving free health services, and were also less likely to report experiences of paying for services or providing non-monetary ‘gifts’ to health professionals. However, even in these provincial districts, participants also believed that the FHCI gives priority health care services to children at no cost more so than for pregnant and lactating women, who are sometimes charged direct or indirect fees.

Most participants, especially in Koinadugu, Bo and Kono, confirmed the availability of FHCI services in their communities. The services mostly associated with the FHCI were malaria treatment, including the distribution of ITNs at no cost, immunisation for children, and sometimes supply of food items such as corn flour and plumpy nuts. These all benefit from vertical programme support, which may explain why they are more reliably supplied.

While participants across the districts and groups overwhelmingly noted that there are costs/fees associated with FHCI services, they also strongly emphasised that their overall expenditure on medical services had greatly reduced following the introduction of the FHCI. The majority of the participants mentioned that their personal health care spending was higher before the introduction of the FHCI. Similarly, most of the participants believed that the high cost of medical supplies, which was previously a huge challenge, had improved since the FHCI began. Men from all four districts were particularly very appreciative of the FHCI, as they felt that its existence had substantially saved them from spending more on the health of the pregnant women and young children in their families.

On the other hand, however, a few participants mentioned that health service expenditures had increased for them since 2011. They mentioned that even though they were not directly paying for

the services received, the sum total of the all the other little payments, including those made to nurses, increased their overall expenditures. This was more a perception in the large towns:

“The free treatment is just for villagers – in big towns we now spend more money” (Adult

male, Bo).

The majority of the participants cited that it was a common practice for nurses to say that certain services and supplies, especially drugs, are not available, when in actuality they have plans to sell them to beneficiaries:

“Services are not always available because the nurses will tell you to go to the pharmacy, and when that occurs, another nurse will call you into a corner and tell you that she has that particular medicine for sale, which is in fact supposed to be free” (Adult female, Western

Area).

The issue of being asked to pay for services was persistent across each district, even for the beneficiaries. A premium was asked by nurses even for child delivery and the amount was based on the sex of the child. Not just limited to birth, payments were also demanded from lactating mothers and children under five for routine problem visits, such as malaria and fever. Failure to pay such charges resulted in no treatment or, in some cases, delivery of half the required

medication doses with a prescription given for purchase of the remainder of drugs at a pharmacy:

“Before, when a pregnant woman gave birth, we paid SLL 60,000 for boys and SLL 40,000 for girls. It is still the same presently” (Adult female, Kono).

Likewise, a female participant in Bo reported that when her delivery date was almost due she went to the health centre but the nurses refused to attend to her. They asked her to pay even though she was in critical condition and had no money. For that reason, she returned home and asked a TBA to help her instead.

In addition, participants in KIIs pointed out that the unavailability of drugs at health centres was a major contributor to the FHCI not working well. Most highlighted that even when the drugs are available at the health centres, the nurses would most times split the tablets and distribute them to their intended beneficiaries. As such patients end up buying extra drugs since the ‘broken-up’ tablets given to them are perceived as insufficient to cure them. Even more disheartening for participants was the fact that some of the drugs they had to buy at the health centre were labelled ‘Free Health Care’.

Nearly half of the FGD participants in the four districts mentioned that the cost of the services hindered them occasionally when seeking health care services under the FHCI. Sometimes participants felt that they would not be attended to if they did not give money at the health centres. Likewise, they thought money was significant if they wanted proper treatment.

Similarly, a few participants in the Western Area mentioned that pregnant women faced difficulties due to the cost they paid for their registration card and for medicines at the health centre. These participants said that after paying for such costs they became penniless and stranded at the health centre with no money for transportation to return home:

“The officials only go on air and talk a lot about how the FHCI is available but when a pregnant woman goes to a health clinic they will keep asking you for money until you are broke to the extent that you cannot pay for transportation to go back home” (Adult female,

6.3.2

Access

Geographic inaccessibility, distance, lack of transport and socio-cultural factors (e.g. household decision-making, perceptions and beliefs) have been shown to be an effective deterrent to care- seeking behaviour even when service-related financial barriers have been removed in Sierra Leone, as elsewhere (Treacy and Sagbakken, 2015). Remoteness and difficult terrain are not just barriers on the demand side but also affect service delivery and quality of care, with difficulty posting staff and ensuring supplies and supervision (Wurie et al., 2016).

The FHCI did not focus on expanding infrastructure, but did aim to upgrade existing infrastructure and so should have some impact on improving access. Analysis of changing coverage of services by rural/urban area (see Section 5.1) does indicate a closing of the gaps for some essential services, although inequities still exist, particularly for skilled attendance at delivery. Socio-cultural factors are discussed in the following section, but here we examine evidence on changes to transport and the referral system in particular, which may be helping or hindering factors behind the changing outputs and outcomes seen to date. They highlight that physical access, transport and a well-functioning referral system remain important barriers for women and children in Sierra Leone, especially in remote areas like Koinadugu and riverine areas like Bonthe.

In the NPSS 2011 report, 67% of respondents in rural areas reported having a health facility within one hour. This is a substantial increase from 2005, when only 48% had a health facility within one hour. However, it appears that most of the increase came before the introduction of the FHCI (see Table 32).

Table 32: Access to government health facilities

Source: NPSS 2011

It may be that the decline was driven by improved roads and transport, more than changes in facilities. According to the NPSS 2011, in 2007 only 20% of rural villages had a PHU in the community. This was still the case in 2011 (see Table 33 below).

Table 33: Villages with clinics in the local community

Source: NPSS, 2011

This finding is corroborated by our FGD participants, who felt that distance may not really be a problem but rather it is the means of transportation is the biggest problem. This is particularly the case in areas like Koinadugu, Kono, and Bo because motorbikes are mostly used to seek health care services there, even when people are in a critical condition.

Some young people in Koinadugu explained that the authorities would not allow pregnant women to be transported on motorbike, which they also felt worsened the situation, especially when there are no other vehicles available. These participants really stressed that the means of transportation is a serious problem, especially in such rough terrain. Some said that the Ebola epidemic made transportation to the health centre more difficult – after Ebola even a motorbike could not be found.

Some TBAs mentioned that they still delivered babies because of the poor road network to the health centre. Likewise, a few participants thought that they would not want to travel a long distance in very rough terrain just to receive a small amount of medicine or delayed treatment. They preferred to buy medicine at the pharmacy instead or seek alternative care, which they thought saved them trouble.