The 10 commandments of health financing following the results of the National Health Accounts 2013

The results of the 2013 National Health Accounts are drawing a picture of funds in the Health Sector in Sierra Leone: where do they come from, how do they flow to which provider and end user. 10 commandments can be drawn from that survey as recommendations for the health sector.


The government of Sierra Leone allocated 11.2% of the national budget to Health in 2013, the highest percentage in the 6-year period beginning in 2008 and an increase from only 8.5% in 2012.[1] Total health expenditure (THE) in Sierra Leone in 2013 amounted to Le 2.5 trillion, or the equivalent of approximately USD $590 million. Of this amount, the government contributed 6.8% of those funds. Donors contributed 24.4% of this spending, and NGOs 7.2%. Out of pocket (OOP) expenditures by utilizers of the health system (households) made up the vast majority of spending, at 61.6%. THE per capita in 2013 was USD $95.10, with donors contributing USD $23.20, GoSL and NGOs $6.50 and $6.80 respectively, and OOP again contributing the greatest share at $58.60 per capita. Out of pocket health expenditures are a heavy burden on household finances, and catastrophic unanticipated health care expenses are a driver of continuing poverty for households in the country.

The greatest amount of expenditures in 2013 went into public hospitals, follow by PHUs (37% and 28% respectively) – combined, the two levels of public health service delivery capture over two thirds (65%) of total health expenditures. Private health facilities captured 9%, pharmacies 4%, and only 3% supported administration / government health administration agencies. This reflects the reality that the majority of health care is provided by the public sector. 85% of all expenditures went into care seeking – 65% going to outpatient curative care and 20% to inpatient services. 10% went to information, education, counseling, and other preventive care programs, with only 2% supporting administration.

While government and NGOs spent around 40% of their contributions on children under 5, Donors spent over half (60%). In contrast, only 20% of OOP expenditures went to under-5s. This reflects the implementation of the Free Health Care Initiative, which is supported largely by donors and is intended to reduce the burden of health care costs for women and children on households. This picture indicates that FHCI is reaching its goals in reducing household expenditure on health care for the target groups, and releasing funds for treatment of older children and adults. However, the high overall OOP expenditures also indicate that households are still struggling despite the reduced burden, and the majority of Sierra Leoneans are not covered under FHCI.[2]


Key recommendations for senior decision-makers are:

1) The high Out-Of-Pocket expenditures show the need for further reductions of user fees, which is also in line with government strategy as stated in pillar 3 of the Agenda for Prosperity.

2) Government expenditures on health as percentage of total government expenditures need to be increased from currently 11% to 15% in order to comply with the Abuja target.

3) In 2013, GoSL was contributing less than Donors and NGOs to total health expenditures. In order to increase sustainability, Government is advised to take ownership and increase their contribution to the health sector.

4) In order to increase cost-effectiveness, it is advisable to spend more on primary care than secondary and tertiary care. Currently, 60% of funds are flowing into hospitals, while 40% are spent on primary care clinics.

5) Every tenth Leone is spent in a private facility. Government is encouraged to invest in public-private partnerships to yield some of the benefits of the private sector while satisfying demand of people.

6) In 2013, epidemiological surveillance and disaster and emergency preparedness were hardly financed, which explains the weaknesses encountered during the fight against the Ebola virus. In order to mitigate that risk in the future, financial investment in that area is needed.

7) Only 3662 Leones (approx 60 cents) per capita were spent on capital investments, such as infrastructures, buildings or similar. Capital investments are the foundations for stronger and more robust health systems for future generations and should be invested more.

8) Both NGOs and Donor organisations are contributing significantly to the Free Health Care Initiative. Maintain the good relationship between NGOs, Donors and GoSL for the continued implementation of the Free Health Care Initiative.

9) National Health Accounts are an annual event to inform Government and key stakeholders about the state of the health sector from a financial perspective. Government can draw part of the Health Financing Strategy and Policy out of this document and should ensure the regular occurrence of the NHA.

10) A large proportion of Government expenditures on health are spent on staff, however, there is still a shortage of health workers, especially in the higher cadres. Government is to invest additional funds into training of health care workers and develop retention strategies both to keep workers in country and at their work station. Make sure to not pay workers who are not showing up at their work station and provide incentives for hard working and well-performing staff (e.g. through Performance Based Financing).

[1] Preliminary expenditure report, Budget 2009-2014, MoFED

[2] MoHS, Sierra Leone National Health Accounts 2013

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