(Un)happy birthday, Ebola! How a financing scheme can restore the health system of Sierra Leone

A year after the declaration of Ebola in Sierra Leone, we are looking back and reflect on our lessons learnt, while fighting the last few remaining cases. It is simple to explain why Ebola could get out of control so easily in Sierra Leone. The reasons range from underfinanced health system, lack of medical education, not having enough staff to weak governance and coordination. We recognised that Ebola was spread and fought in communities. Being plain honest: I have been thinking a lot that we probably wouldn’t have ended up in such a chaos if more money would have flown directly to health facilities and therefore communities. They could have protected themselves as much as possible and would have had incentives keep providing essential health services, while feeling protected. There is an example of a Maternal and Child Health Post in Gbongboma who constructed a holding center out of palm trees, to the best of their abilities. Initiatives like these finally allowed the spread of Ebola to slow down – interventions at community level. They need to be at the heart of any recovery strategy.

As part of the post-Ebola recovery plan, Sierra Leone is implementing a performance financing scheme. The Performance Based Financing (PBF) scheme is paying incentives to health workers and investments for health facilities based on its number and quality of services provided. It is more than “just” financing: it is a systems approach, improving quality and quantity of services through regular supervision and agreed targets. Service provision, verification, supervision and payment function are clearly separated, hence increasing accountability. The reputation of Sierra Leone’s Ministry of Health and Sanitation has been questionable before Ebola and the unaccounted one third of Ebola funds as highlighted in a recent audit report did the rest. Donors are not trusting the Ministry, which meant that a large part of the Ebola fight was outsourced to more reliable partners. The Performance Based Financing scheme is an opportunity to restore trust in the supervising Ministry as well as providing much needed funds for essential health services. A results-based approach means that monthly updates will be provided on the indicators covering a comprehensive package of health services, only paying for actual services delivered. The performance framework guarantees that health workers who work harder and better, also earn more.

Maybe the most important aspect of the scheme is its strong voice for patients and communities: patient satisfaction surveys are essential part of the scheme and will influence the incentive payments. This is a much needed addition in the Sierra Leone health sector, where it generally is a challenge to get patients adequately represented and listened too – even though they are the main stakeholders in the health sector. Community committees are part of the designing of business plans of health facilities. Let them decide, what they need and want from their health service provider. This way, they can prepare themselves for other epidemics and do not need to wait on the central level Ministry to intervene.

The PBF is restoring trust of patients in the health system through increasing its quality and social marketing strategies. It also motivates and equips health staff again to do their work, while leaving them the autonomy to manage their own facility. Cash injections into the community through the health facilities increase local ownership and also have economic multiplier effect: the local carpenter can pay the school fees of his daughter with the profit he makes from fixing a delivery bed, for example.

The total funding needed for the next five years of recovery in Sierra Leone is up to 1 Billion US-Dollars. Spending money through a results-based approach like PBF is four times as efficient as traditional input financing, which means that any dollar raised to help Sierra Leone recover from Ebola is best spent through PBF, making it equivalent to four dollars otherwise spent. In a pilot PBF scheme running now, 1.2 Million US-Dollars are sent over six months directly to 110 health facilities. Small money relating to the overall recovery strategy, big money for the receiving facilities. Bringing market approaches to the health sector doesn’t make it evil: it is a necessary move to make it work more efficient, effective and transparent. All attributes are much needed in the Sierra Leone context.

PBF Verification in Makeni

PBF Verification in Makeni

The hospital secretary and the financial officer of Princess Christian Maternity Hospital in Freetown

The hospital secretary and the financial officer of Princess Christian Maternity Hospital in Freetown

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

Some Q&A at the height of the Ebola outbreak in Sierra Leone

Interview of Maria Bertone held in November 2014 with the Directorate of Policy, Planning and Information of the Ministry of Health and Sanitation in Freetown

  1. Introduction

Noemi Schramm, Acting Unit Head & Health Economist, Health Financing Unit, DPPI, MoHS, GoSL


  1. Interview questions

From our offices in Europe, reading daily Ebola updates and news, we tend to imagine that nowadays a city like Freetown, the capital of one of the countries most affected by the outbreak, Sierra Leone, would look like as a barren, empty, post-apocalyptic town. Perhaps our perceptions shaped by the footage of the “lockdown” (http://vimeo.com/106806835) – when a three-day curfew was imposed on the entire country of Sierra Leone to allow volunteer to go house by house to sensitize the population and track down suspect Ebola cases (LINK). For those who know Freetown and West Africa in general, it was shocking to see empty roads and such eerie quietness.

How does the city look like today? What is the dominant atmosphere? Is everything close down or are shops and markets open and people fill the streets as usual and report regularly to work?

Life is going on as normal – with some small limitations. People are not shaking hands anymore, taxis and poda-podas (mini buses used for public transport) are less crowded and clubs are closed at night. However, people are still selling, buying, going to work, organizing their lifes, visiting family and friends and catching up with the latest football news. As most of the small cinemas showing football games are closed now, people with TVs in their house have become popular! Churches and Friday prayers are still allowed to happen and people spend significant times following religious services. As schools are closed, there are more children on the street either playing or selling things. So yes: life is bustling as normal during the day, but probably a bit quieter in the evenings. However, this obviously also depends on what community you live in. There have been isolated disturbing scenes in the East of Freetown, but the city never collapsed as much as Monrovia did. There were no public riots, no panicking public. Sierra leoneans are very resilient.

What are the main challenges for people’s daily life in Freetown?

Paying for food. Food prices have gone up and combined with less jobs or less secure jobs available, providing for the daily needs is even more of a challenge now. Furthermore, the situation in some rural parts of Sierra Leone is devastating and people are asking their family members in the city for increased help, which puts further pressure on people’s already limited financial resources.

This is a song circulating on the web (http://www.youtube.com/watch?v=0bo8s98t_g8). Have the information and community awareness efforts on Ebola improved people’s knowledge of the precautions? And if so, what were key determining factors (community health workers, social media, media, …)? Did the “lockdown” play an important role?

Everyone has heard of Ebola. However, the level of knowledge differs, as well as the level of belief in the messages. People still think that bushmeat is one of the major sources of transmission, even though there has only been one confirmed case of animal to human transmission. People are hearing the Ebola messages all day long, but sometimes it is just not possible to implement them – they might live in very crowded places, sharing latrines (if even available), eating food out of one pot or not having enough water to wash (hands) regularly.

The lockdown was called a success, but infection rates are still soaring. My impression is that a lot of people know some facts, but if it comes hard to hard, if your husband or your mother or your child is screaming in pain in your house and the free toll line 117 is not answering your calls for help for hours, everyone is a human. There are not enough treatment beds, so people are being sent home with very basic instructions on how to take care. Often, there is no other option than to touch the patient, with limited protection possible.

What do people in Freetown think of the international response? Too little, too late, or …? How do they see the international and domestic health workers with their PPE space suits, etc.? Is trust in the health system increasing or not, or is it too early to tell?

There is a general sense of disappointment. The British response is very slow, of the six treatment centers promised only one is opened and only working on a 10% capacity – three weeks after the opening. It is not understood what takes them so long to build treatment centers and what makes them turn away patients. There is a sense of a two-class treatment – with international workers getting evacuated quickly and being provided medical care (on board of the Argus, the military ship), while Sierra Leoneans are left to die in their houses. All Sierra Leonean doctors that got infected with Ebola died so far (one still fighting for his life at the time of writing). It is also not understood how the UK can invest so much money into fighting the disease here and at the same time cancel flights – the cancellation of the British Airways flight beginning of August started a whole chain of panic that probably cost the Sierra Leonean economy more than what is given every year in aid money.

The PPE space suits are scary and are carrying a message of death. People know that when somebody like this is carrying away your loved one, chances are high that you might not see that person again.

Trust in the health system has been weak pre-ebola and was still recovering from the civil war, when the outbreak hit. It will take time to rebuild and continue to strengthen the health sector. However – this time around the whole health sector is hit, including traditional healers. So instead of previously choosing traditional healers over public health care, people are now choosing no health care over the possibility of being infected with Ebola.

Some argue that the presence of urban slums and their mobile populations play a role in the spread of the Ebola epidemic (http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(14)70339-0/fulltext). Which factors do you think allowed Ebola to spread so fast and widely in Sierra Leone?

Part of it is the dense population and uncontrolled movements, but also the lack of organization on community level. Poor areas were just left on their own with limited interventions from top-level. There is a need for way more community-based Ebola response centers, which can actually track each individuals.

Furthermore, there are lots of really bad decisions being done on the politics side of the ebola response. Unnecessary power fights (in government, between national and international partners, etc) do not help containing the outbreak.

We understand that new Ebola cases are now diminished in the provinces where the epidemic started (Kailahun, Kenema, ..), but there are increasing in other provinces (Port Loko, Bombali, …). Do you have an idea of the situation in the remote villages of those provinces? DO you have a sense that a ‘turning point’, the peak of the epidemic has been reached somewhere, and the worse is to come elsewhere? What about Freetown?

Some villages in the original epicenters are now starting to rebuild their communities. Fields have been abandoned, family structures changed, market situations are deteriorated. Some villages have come up with their own recovery strategy and are working towards rebuilding their communities. However, my impression is that the new epicenters are still very much in a panic mood. The turning point has not yet been reached. Especially in Freetown – it is difficult to see the light at the end of the tunnel.

What is happening at the Ministry of Health and Sanitation (MoHS)? Is everyone regularly reporting to work? Is staff screened for fever or other symptoms?

Staff is coming to work regularly and a lot are working hard to contain the disease. People are generally tired after having been fighting for more than half a year.
Security measures have tightened, there are chlorine buckets everywhere and thermometers that are used sporadically.

I read that a new National Ebola Response Center (NERC) has been established on the premises of the former Special Court for Sierra Leone (10-15 minutes drive from the MoHS in Youyi building), in order to ensure coordination in the efforts to fight Ebola. Have some staff or Departments of the MoHS been seconded or moved there? What is the role of the MoHS in the Ebola response? What is the role of the major international organizations (UNMEER, WHO, CDC/USAID, DfID, NGOs, Global Fund, GAVI, etc.)? How is the coordination/cooperation happening in practice?

Yes, some staff has been seconded to the NERC. Some staff has been seconded to the call center as well. MoHS was told by the president to focus on our usual work and continue with the previous projects as much as possible. This is good, as it is important to keep providing other services as well, however, it led to power fights as the doctors and MoHS feels undermined. A lot of money is channeled through the UN agencies now, after some initial problems with GoSL structures. UNFPA is responsible for contact tracing, Unicef is a logistics hub, World Bank is paying hazard pay to health workers, Red Cross and World Vision is responsible for the burial teams. The burial teams were previously managed by the Directorate of Reproductive and Child Health of MoHS, which obviously didn’t make sense at all. It was outsourced now through a contract. NGOs in cooperation with Ministry of Social Welfare is taking care of orphans and survivors. Coordination and cooperation is happening at NERC.

I noticed that the new MoHS website (http://health.gov.sl/) is very much focused on the Ebola response, and there is little on the other programs. The DPPI is usually quite busy with the management of the health information system (HMIS) on the one hand, and with the planning and managing of numerous health financing issues – you manage the country-wide Performance-Based Financing (PBF) system, you are preparing the National Health Accounts report, discussing the future of health financing in Sierra Leone, etc. What is the DPPI working on today?

We have been pushing hard to keep existing projects going, especially the PBF scheme. It is of utmost importance to 1) get money to clinics which they can use for general Ebola protective gear for example and 2) incentivize treatment of non-ebola diseases. However, it was difficult to persuade donors and partners that it makes sense to not stop all non-ebola activities. But up till now the PBF scheme is running, which is a success in itself. Furthermore, the NHA report is in its final stages and was just verified in a validation workshop with stakeholders, data validation was done on the HMIS, etc. The data system is important now, as it tells us about utilization of public health facilities. We have done some analysis and found no significant differences up until September, where utilization started dropping significantly. We are still completing October data. DPPI is very busy and also involved in the post-ebola strategy. Field missions have been completed and ideas are now being thrown around on how to rebuild the system.

There are many calls in blogs and discussions not to forget the importance of broader health system strengthening efforts in the fight of Ebola. Some estimate that the excess non-Ebola related deaths are substantial as people decide not to seek treatment in health facilities (LINK). What do you think are the main issues and challenges for the health system in this emergency? Are there health systems strengthening efforts that can be taken while addressing the Ebola emergency? What could be done / you are doing to support health system strengthening at the moment, and what should be done in the future?

Keep existing programs going – look at the PBF scheme. Inform policy makers on the health system now with all data available to allow for thorough planning of post-ebola strategies.

What do you think will be crucial to end this Ebola outbreak?

Behaviour change. I hope that the continued soaring of Ebola is a wake up call and people finally start being responsible for their families and neighbours and stopping the transmission change! Furthermore, I feel like the huge inflow of humanitarian emergency money has spoilt the health workers. More patriotism is needed and a higher sense of duty and responsibility for Sierra Leone. For the international community: stop looking in your own four walls and start thinking globally – this disease has to be defeated here. Panicking and stopping flights are not helpful. Stop the stigmatization of West Africa(ns) and send any help you can.


Ibrahim is a young professional working as a Monitoring and Evaluation Officer in the Ministry of Health and Sanitation. He has a one year old son (and obviously future great football player) called Ibrahim Junior and a very smart wife named Hawa. He was quarantined in January 2015 because there were two Ebola cases in his compound. Food was supplied to him during the 21 days, but no provisions were made for Ibrahim Junior, who obviously has different needs as a baby. The Schramm Connection provided him with money for baby food and other needed supplies. They were released out of quarantine after 21 days and Ibrahim is happily playing football again for a local club called FC Plantain – and obviously hoping for Ibrahim Junior to join him soon on the football field.

Ibrahim doing his work as Monitoring & Evaluation Officer

Ibrahim doing his work as Monitoring & Evaluation Officer

Ibrahim and his baby son receiving donated money during their 21 days in quarantine

Ibrahim and his baby son receiving donated money during their 21 days in quarantine