An update on the Sierra Leone Social Health Insurance

  • Overview of Sierra Leone Social Health Insurance


The Sierra Leone Social Health Insurance Scheme (SLeSHI) is about sustaining Free Health Care in Sierra Leone and ultimately reaching Universal Health Coverage. Beneficiaries of any of the free health care initiatives (pregnant and lactating mothers, children under five and people suffering from Malaria, TB or HIV/AIDS) will all be exempt from premiums. However, the financing structures to pay for their treatment can be part of the wider financial structure for Government provision of public health care. In this way, the scheme should both help Government raise money for health care and create the unified structures necessary for Government to buy into health care that is currently largely donor funded.

  • SLeSHI: Progress and achievements


The Government has constituted a Technical Committee comprising of representatives from both Government institutions and partners to design SLeSHI. A blue print has been developed, pilot districts selected (Bo and Koinadugu), institutional arrangement approved whilst the benefits package is being designed. Additionally, preparatory work is at an advanced stage for an impact evaluation that will not only assess willingness and ability to pay for the scheme, but will also provide the baseline that will be used to assess the impact of the scheme after the pilot. A pre-pilot was conducted in rainy season and the questionnaire was administered to health workers, communities and patients. Furthermore, it was planned to use mobile credit vendors as a distribution channel for the insurance policies. The method was tested at some vendors and their feedback obtained. The premium is yet to be defined, but if there could be found a way to pay smaller amounts regularly, the system using the mobile credit vendors could be a success.

A facility assessment is being planned in order to provide an overview on the situation of the facilities in the two pilot districts. The assessment will include public, private and faith-based facilities and also hospitals, laboratories and community-led referral system. The general infrastructure of the district (transport, communication, human resources) shall be analyzed too. The facility assessment could also be done through desk analysis, using existing findings.

  • SLeSHI: Outlook and recommendations

SLeSHI was paused due to the Ebola outbreak. The President assigned the lead of the project to the Ministry of Labour and Social Security to re-commence progress.

Another option that has come up during the pre-pilot in the field, was to make it a two step process and change the design slightly. In a first step and to encourage people to use the facilities again, all drugs at primary care level could be made free. Apart from the free health care drugs, the amount of drugs distributed at primary level was USD 200,000 in 2013. It would probably be possible to make all drugs free for a cost of less than USD 1,000,000, which could be a very cost-effective way to increase trust into government facilities again. However, another approach would be to redesign the Free Health Care Initiative slightly to target the poor. This could work through the Performance-Based-Financing PLUS scheme, which would pay higher subsidies for vulnerable patients. Making all drugs free could on the contrary be regressive (anti-poor) again.

In a second step, secondary care could be included in an insurance scheme. During the pre-pilot, it became clear that a lot of people go directly to hospitals or are referred to hospitals because they can’t be treated in PHUs. There is a need to cover this cost.

In the academic discussion, a voluntary insurance scheme which SLeSHI would most resemble in its current design, is regarded as not effective, nor efficient. Administrative costs are high and in the case of SLeSHI would have constituted more than 100% of the premium for each insured. That means that SLeSHI would create additional administrative structures but not address the issues on the ground of quality of care. Furthermore, the effect of health insurance in Africa is currently at the heart of the debate and results from existing insurance schemes are discouraging. The current SLeSHI design as it stands has to be reviewed carefully in order for it to achieve its target of better and wider access to care and protection against health risks.

A review is planned to take place in 2015 to assess the feasibility and options for a National Health Insurance in Sierra Leone. The advice of the technical personnel being involved so far is to hold on for now and focus on other ways to strengthen the health sector. In essence, SLeSHI would cost more than raise for Government and likely fail to reduce poverty.

An update on Performance Based Financing of health facilities in Sierra Leone

  • Overview of Performance Based Financing


Performance Based Financing (PBF) was introduced in all 1200 public health clinics and selected private clinics in 2011. It is funded through the Reproductive and Child Health Project from the Worldbank and has so far sent about 15 Million US Dollars directly to facilities, who have invested 40% of that money in upgrading and maintaining the facility and the remaining 60% as incentive for staff performance. The project was externally verified through Cordaid in 2013/2014, who found increased motivation of staff and that small investments were being done, but also large disparities in data collected, weak financial management structures and generally low knowledge and capacity in the scheme.

With support of Cordaid, the Ministry has now developed a plan to move towards PBF PLUS as a first step to strengthen the health system in the Ebola recovery phase. PBF PLUS is addressing the weaknesses of the existing scheme and aims to increase transparency and governance, as well as ownership of the Ministry in the health sector. It addresses some of the key issues of the ministry such as low quality of services, under-financing of the health sector, weak coordination and decentralization and low transparency.


  • PBF light

The current scheme is called PBF light, as its design is not fully reflecting PBF standards. It resembles more a payment scheme with some pay-for-services elements. It has been administrated from national level, with verifications being done by the DHMTs. The scheme will be upgraded slightly in 2015 to prepare the health system for the move towards the PBF PLUS.

The PBF light scheme is an integral part of service deliveries at PHU level. Health workers motivation is highly linked to PBF payments and the direct cash flow has allowed basic maintenance and investments. The World Bank has been funding the PBF scheme through the Reproductive Child Health Project 2, which runs until October 2016. From the beginning, the idea has been that Government buys into the PBF scheme and starts contributing to service delivery at primary level using the PBF. However, the World Bank remains the only funding source and the scheme is now running out of money. RCHP2 allocation is enough to pay incentives up until the end of March 2015, which means that facilities will receive money up until about October 2015, as payments are done after delivery of services. There is an urgent need to raise 2.1 million US Dollars to keep paying the facilities or find another solution for the future of the PBF light.



The PBF PLUS scheme is implementing a full PBF structure with clear separation of functions, higher autonomy of the facilities while having regular supervision, a comprehensive indicator list and feasible prices being paid for services and quality at facilities. The payment structure is going to be simplified in order to decrease payment delays. Clear separation of functions (Verification, service delivery and payment) leads to greater governance and transparency. The Ministry can easily take ownership of the indicator list and quality checklist and guide the health service delivery in the direction it wants. At the same time, results are clearly visible and can be tracked.

The PBF PLUS will be piloted in Bombali in the second half of 2015 before being evaluated and rolled out nationwide. The idea is that Government is flowing part of their budget for health through the PBF and strengthen primary and secondary care services through a clear performance approach, where facilities who perform better also receive more money. The total funding needed is 24 Million US Dollars, where among other donors the World Bank is willing to contribute, if the Government buys in as well.