Mabinti Brima (right) with two of her children and a grandchild. Mabinti's daughter Sia died while five months pregnant
Mabinti Brima’s home is a two-room shack sheathed in rusty corrugated iron. She shares it with 11 members of her family: daughters, their husbands, grandchildren. None have any formal work. Mabinti makes a living by selling cooked chicken offal in the alleys snaking along the hillsides of Dwarzak Farm, one of the biggest slums in Freetown, capital of Sierra Leone.
The shack stinks and it seems improbable that 11 people live there. But now there is one less person to fit. A few days before my visit, Sia Brima, Mabinti’s eldest daughter, collapsed after three days complaining of “pains in her bones.” An ambulance was called but Sia died before it arrived. She was 24, engaged to be married and five months pregnant.
Like her mother, Sia suffered from sickle-cell anaemia. Even in the developed world, 20 per cent of babies born to mothers with this disease will be premature or underweight and there are serious risks of miscarriage. But no one knows what killed Sia. Her body was buried the same day, without an autopsy. The death certificate recorded “sore bones.”
It was just another death in an African slum, in a country where one in eight women die from complications in pregnancy and childbirth. Yet Sia’s death, like the majority of those occurring to pregnant women in Africa, was avoidable.
Sia had no antenatal care. On the first day of her pains, she went to see a “private doctor.” He sold her folic acid pills and advised her to go to the state-run Princess Christian Maternity Hospital. But Sia couldn’t afford it. A consultation at the hospital is at least 5,000 leones (85p), and treatment much more. This is well beyond the means of the average Sierra Leonean, 70 per cent of whom live on less than $1 a day.
Sia lived ten minutes’ walk from a health clinic—but she couldn’t afford to go there either. The George Brook clinic was built by Unicef and is run by the government and NGOs. A first visit costs 25,000 leones (£4.20). Women who don’t pay may be detained until their family coughs up. It would take Mabinti two weeks to earn 25,000 leones. “But I would have done it,” she told me. “I would have done anything. Sia was my eldest, my helper. She was a pillar of this family.”
Sierra Leone regularly posts the worst child and maternal mortality rates in the world. Since its civil war ended in 2002, aid has poured into the country, inspired in part by the UN millennium development goals, targets for the reduction of emblematic indicators of poverty. But aid usually comes with conditions attached—like the fees that priced Sia out of antenatal care. These fees are part of development orthodoxy, espoused for over 20 years by the World Bank and agencies like Unicef and the World Health Organisation (WHO).
I walked down through the slum from Mabinti’s house to the clinic. It was very quiet. Four pregnant women gossiped in the sun as they waited to be seen. On the ward, only one of the eight beds was occupied. In the office of Albert Vandy, community health officer, a yellowed sheet pinned to the wall gave the health statistics for Dwarzak Farm: it said three in every 20 children born in the valley die before the age of five.
I asked Vandy about Sia’s death, which he hadn’t heard about. “No one is refused care,” he said. “Any fees are according to a person’s ability to pay.” But there is a big incentive to extract fees from women as they are vital to the clinic’s running costs, though Vandy said he didn’t use them—as some clinics do—to augment salaries. (Unicef subsequently told me they had no objection to the fees—“the important thing is that there is a clinic with trained staff and the right drugs.”) Vandy earns 144,000 leones (£25) a month, the nurses 120,000 (£20): the worst rates for health staff in Africa.
In the yard stood the clinic’s ambulance, a Land Cruiser. Through its topcoat of orange dust you could make out the logos of the UN Population Fund and Japan’s Maternal Mortality Reduction Project. No one could use it, Vandy said, unless they paid 25,000 leones (£4) for fuel. What was the local maternal mortality rate? “We don’t know,” he said apologetically. “So few of them are reported to us.” I asked him why he worked here, when he could earn five times as much working for an NGO. “I want to serve my nation,” he said.
***
Ten years ago this May, I went to Sierra Leone to report on the despatch of a small British taskforce of paratroopers and special forces to the country. Brigadier David Richards (now chief of the general staff) was in charge. His task was to bolster a UN peacekeeping force on the point of losing control of Freetown to the rebel militias who had taken most of the country. There was no strategic or commercial interest, and not much from the British public either. It was new Labour’s “foreign policy with an ethical dimension” in action—and it worked; in fact, it may have been the only successful military intervention by a colonial power in one of its former possessions in history. (While I was there in January, several people told me wistfully that they would like Tony Blair as their president.)
Robin Cook, then foreign secretary, promised to “rebuild Sierra Leone.” British civil servants were seconded to the shattered ministries and a retired chief constable from Manchester took charge of the police. A massive aid programme began: to this day, Sierra Leone receives more British aid money per capita than any other African country.
In 2000, the same year as Britain’s intervention, the UN agreed the millennium development goals. There are 15 of them to be achieved by 2015, and all are up for a review of progress this September. The fifth goal states that maternal mortality should be cut by three quarters by 2015.
Sierra Leone will come nowhere near meeting this goal. The country’s rate of 2,000 mothers’ deaths per 100,000 births (according to Unicef and the WHO) is perhaps the highest in the world. The sub-Saharan African average in 2005 was 900; in western Europe it is nine. In sub-Saharan Africa, 250,000 women die in childbirth every year, a third of them because of something as simple as a haemorrhage. In many countries childbirth is the most common cause of death for young women. Maternal mortality is reducing in sub-Saharan Africa but only very slowly—and of all the millennium development goals, the pledge to address the unnecessary death of mothers is furthest from fulfilment.
Death in childbirth is an unambiguous tragedy, and it touches the rich world’s conscience with ease. Across the world, premiers’ spouses (including Sarah Brown) have campaigned for maternal and child health. Perhaps as a result, funding for this area has soared—from £1.4bn to £2.3bn a year between 2003 and 2006, according to Oxfam. Spending on health in the developing world tripled in the noughties. So why are maternal mortality rates still so high?
There are two answers from development analysts. One is the fashionable “aid doesn’t work” line, promoted last year in Dead Aid, an influential book by Dambisa Moyo, a Zambian-born economist. This has been taken up by economists like Jagdish Bhagwati, and leaders like Rwanda’s Paul Kagame and former UN secretary general Kofi Annan. Moyo says that pumping money into countries without the systems to employ it properly fosters clientelism, dependency and corrupt and inefficient governments. She may have a point. In the past three years, Sierra Leone has received over $250m from Unicef, Britain’s department for international development (DfID) and the World Bank to tackle health—and its former health minister is awaiting trial on corruption charges.
But there is another argument expounded by the likes of Oxfam, which is about to publish a paper, “Aid in the 21st Century.” It holds that when aid fails it is partly due to the conditions and ideas that aid donors impose on recipient countries.
***
If aid can go wrong in many ways, the factors behind maternal mortality are just as numerous, starting with cultural issues. Women who have been circumcised are more likely to have problematic first deliveries. In some polygamous societies the value of a woman’s life is so low that families may not be prepared to pay for their healthcare. An “obstructed” labour may be seen as a sign that a woman has been unfaithful. All of these factors apply in Sierra Leone.
So do problems of infrastructure and personnel. To prevent deaths in childbirth, countries need midwives and surgeons, and the facilities to perform operations. The brain drain to the developed world, especially of nurses and midwives, has long hindered poor countries. Sierra Leone has just five gynaecologist/obstetricians and 95 midwives serving over 3m women. Six of the country’s 13 districts have no emergency obstetric facilities. As a result, less than 1 per cent of births are by caesarean, while the rate in societies with full access to healthcare is 8 or 9 per cent. Clearly, the women caught in that tragic statistical gap are likely to die in labour.
But in three other areas, attempts to improve maternal health (and infant survival) have faltered because of the ideological preoccupations of donor nations. These are, in ascending order of importance: dependence on traditional birthing systems, the withdrawal of funds for family planning and, most controversially, charging for access to medical services.
In the first area, attempts were made to deal with the lack of health workers by beefing up systems which had existed for centuries. In many countries, particularly in Africa, large sums were spent in training village “wise women” to be traditional birth attendants (TBAs). The results were disappointing. Too often, it was found that TBAs were less likely to seek professional help when births started to go wrong. According to Ibrahim Thorlie, chief consultant at Princess Christian Maternity Hospital: “If you want to reduce maternal mortality, there is no place for the TBA. When they try to deliver abnormal deliveries they create problems for us, and they cause deaths.” You cannot get modern survival rates without modern facilities.
The second area is pure ideology. While increasing health spending in Africa, the Bush regime withdrew funds from family planning, driven by the Christian right’s desire to promote abstinence. It is hard to assess the impact of this, but last year the UN calculated that 215m women worldwide do not have access to contraception. In Sierra Leone, it is thought that less than 4 per cent of women use it.
Ideology also drives what may be the most important factor: user fees. In 1987, the WHO and Unicef convened a summit in Bamako, Mali. At the instigation of the World Bank, African health ministers agreed to introduce point-of-use fees, as part of the “structural adjustment” plans being applied to developing countries to reduce state spending.
The user fees principle, known as the Bamako initiative, was supported by the key international players in health and donor countries like Britain. The World Bank estimated that the income from user fees could contribute 15-20 per cent of health budgets. Fees would also cut waste and “frivolous” use, especially of drugs. What you pay for, you use properly: the same argument that introduced prescription charges in the NHS.
By the mid-1990s, the Bamako initiative was a central plank of aid policy for public services. Most of the poorest countries implemented fees as they reformed their health services. World Bank and IMF loans for health were conditional on fees being introduced. By 2000, all but three African countries were officially charging user fees.
But as research on their effects started to emerge, opposition to their use grew. Some of the more radical aid organisations, like Médecins Sans Frontières, Oxfam and Save the Children, mounted campaigns against them. The UN and financial institutions remained adamant in their support, even as evidence showed that user fees were discouraging the poorest from using health clinics.
Fees also forced the poor to sell assets or borrow at exorbitant rates when ill. In the Democratic Republic of Congo, it was reported that fees had stamped out “frivolous” use of healthcare to the extent that the average person only visited a clinic once every 6.7 years. Across Africa, fees only brought in some 5 per cent of health budgets—far less than the World Bank promised. Meanwhile, health statistics failed to improve.
But the World Bank and other institutions would not back down. The authors of the Bamako initiative were still largely in office, and, as one analyst said, had “built their careers on user fees.” A spirited defence was mounted, which claimed that when a health system ran properly—meaning that donor funds were being spent on health workers’ salaries, rather than disappearing further up the chain—the system worked.
Unicef stood by user fees and has yet to disown them. In 2005, it produced statistics showing that if services improved, then usage of them increased. But it was clear from the UN agencies’ figures that in most countries, take-up was going down. In the more dysfunctional countries, fees had become the only means of keeping primary health clinics going—and a key element of the pay of those who worked in them.
Half the staff in some Freetown clinics are dependent on fees for their salaries. And when underpaid doctors and nurses have a direct interest in the collection of fees, things can go wrong very quickly. You don’t have to go far in Sierra Leone for an explanation of the country’s maternal mortality rates (of which everyone is deeply ashamed). It is that state clinics kill mothers because of the staff’s demand for fees. “They told my wife that she would have to have the baby cut out. They wanted a million leones. So she said she would trust in God, had the baby at home and she was fine,” said the restaurant manager at my hotel. Evidently, badly applied fees destroy people’s faith in state healthcare.
***
The rebellion against the user fees orthodoxy began in earnest in 2001. A few days before an election, the Ugandan president Yoweri Museveni announced a new policy of free healthcare for all. Rob Yates, now a senior health adviser at DfID, was then working on secondment at the Ugandan ministry of health. “I was a signed-up believer in user fees, and very dubious that the policy would work,” he says. But Yates was soon persuaded. After free healthcare started, attendance rates at primary healthcare clinics doubled. Half the take-up was from the poorest 20 per cent of people. “User fees were plainly excluding the poor—the very people the aid was designated for in the first place.”
Yates and others started to spread the news, armed with a telling amount of evidence. In Kenya, if you charged women just 50p for an insecticide-treated bednet (one of the most effective low-cost prophylactics against malaria) demand dropped 75 per cent. Uptake of deworming drugs—an important factor in child development—dropped 80 per cent if a small charge was applied. And in October 2005, the Bamako initiative received a fatal blow from a paper in the British Medical Journal. The study took epidemiological data from 20 African countries and projected what would happen if user fees were removed. The conclusion was that, each year, the lives of 233,000 children under five would be saved.
Taking note of Uganda’s success, in 2006 Senegal and Burundi promised to provide free healthcare at birth—despite continued opposition from international agencies. But donor countries began to change their minds. In a 2006 white paper, DfID announced support for countries who wished to remove user fees, soon followed by the EU.
By then, many of the analysts believed that dropping user fees could be by far the most cost-effective intervention on maternal and child health. Coupled with universal immunisation, it might mean that poor African countries could, after all, meet their millennium development goals on health. Almost 60 per cent of births in Burundi are now in health facilities—up from less than 25 per cent five years ago. Zambia, Burundi, Niger, Liberia, Kenya, Senegal, Lesotho, Sudan and Ghana have now dropped fees.
In April, Africa’s poorest country will make its move. With DfID’s support, Sierra Leone will drop fees for children under five and pregnant women. This will cost $91m in the first year—of which Britain is contributing about 10 per cent—and involves a 35 per cent increase in the health budget. But dropping user fees need not be so expensive. Uganda’s move increased the health budget by $1 per capita to $9 in the first year; Sri Lanka now provides free healthcare at $23 per head.
There are voices that urge caution. Dan Harris, a researcher at the Overseas Development Institute in London, observed the transition in Uganda. He says that soon after dropping fees in 2001, old problems resurfaced. “The huge increase in usage resulted in shortages of drugs and led to people having to seek them from private providers. Ultimately, the number of people having to make catastrophic payments for healthcare didn’t go down much.” Chris James was lead researcher on the BMJ paper and now works for the WHO in southeast Asia. He says: “There are risks in dropping fees too swiftly and you’ve got to make sure there is alternative funding in place, especially for health personnel.”
***
Back in Freetown, the Princess Christian Maternity Hospital gleams in newly-painted white, like an ocean liner stranded on the grubby reef of the tumbledown city. Built in 1925, it is the only maternity hospital in the country. In a city where 1,000 women die in childbirth every year, you would expect it to be pretty busy.
But inside the compound, after negotiating a car park packed with 4x4s stencilled with the names of big NGOs and UN agencies, we enter the calmest state hospital I’ve ever seen—in Africa or Britain. Lounging around the admissions desk are three nurses. It is 4pm, and in this hospital of 150 beds they have received seven expectant mothers today.
Ibrahim Thorlie, the chief consultant, tells us that a caesarean costs 400,000 leones ($100) while an ordinary delivery costs 160,000 (£28): a month’s salary for a senior nurse. If a transfusion is needed, relatives have to give blood first. Is this why the hospital isn’t busy? “Of course!” says Thorlie.
“But we perform emergency caesareans every day free,” he says as we tour the wards. “We have to—there are families who just dump the mothers here and run away, because they are frightened of the debts. Women sometimes disappear when the operation is done.” In fact, community health officers told me that women have been refused treatment unless cash was provided first.
Thorlie acknowledges, “a lot of women die because they don’t want to come to hospital.” Worse perhaps than that, a lot of women die because they come too late—probably put off by the fees. For all its impressive facilities, the hospital has a dreadful record: in the first six months of 2008 9 per cent of the 900 or so mothers who gave birth here died. So what does he think of the plan to remove user fees: “We’re ready to make it work and do all that is provided but one thing is crucial. Our salaries must be augmented.”
The World Bank, chief ideological sponsor of user fees, now says it will not object if a country drops fees for healthcare. It is likely to bankroll the increases in health workers’ salaries in Sierra Leone. Funding healthcare remains a hot topic of debate. The big medical agencies now favour forms of health insurance, but that is only likely to work in places with good health services. There are more radical ideas around, especially in areas like infant health. Grants are given to expectant mothers in some Indian states to spend on any aspect of care; Mexico has done the same. In parts of Sierra Leone, the authorities have started fining women if they don’t give birth at clinics. Oxfam proposes that maternal mortality rates be seen as the key indicator of a country’s performance, rather than the numbers of health workers or per capita spend.
Most important of all, Rob Yates pleads that in future we look for evidence of whether rules will work before imposing them on poor countries. “This process did not seem to happen in the late 1980s,” he wrote in the Lancet. “We should have known that taking money from poor people when they are sick is not a good idea.” Sia Brima could have told us that too.
Mabinti Brima’s home is a two-room shack sheathed in rusty corrugated iron. She shares it with 11 members of her family: daughters, their husbands, grandchildren. None have any formal work. Mabinti makes a living by selling cooked chicken offal in the alleys snaking along the hillsides of Dwarzak Farm, one of the biggest slums in Freetown, capital of Sierra Leone.
The shack stinks and it seems improbable that 11 people live there. But now there is one less person to fit. A few days before my visit, Sia Brima, Mabinti’s eldest daughter, collapsed after three days complaining of “pains in her bones.” An ambulance was called but Sia died before it arrived. She was 24, engaged to be married and five months pregnant.
Like her mother, Sia suffered from sickle-cell anaemia. Even in the developed world, 20 per cent of babies born to mothers with this disease will be premature or underweight and there are serious risks of miscarriage. But no one knows what killed Sia. Her body was buried the same day, without an autopsy. The death certificate recorded “sore bones.”
It was just another death in an African slum, in a country where one in eight women die from complications in pregnancy and childbirth. Yet Sia’s death, like the majority of those occurring to pregnant women in Africa, was avoidable.
Sia had no antenatal care. On the first day of her pains, she went to see a “private doctor.” He sold her folic acid pills and advised her to go to the state-run Princess Christian Maternity Hospital. But Sia couldn’t afford it. A consultation at the hospital is at least 5,000 leones (85p), and treatment much more. This is well beyond the means of the average Sierra Leonean, 70 per cent of whom live on less than $1 a day.
Sia lived ten minutes’ walk from a health clinic—but she couldn’t afford to go there either. The George Brook clinic was built by Unicef and is run by the government and NGOs. A first visit costs 25,000 leones (£4.20). Women who don’t pay may be detained until their family coughs up. It would take Mabinti two weeks to earn 25,000 leones. “But I would have done it,” she told me. “I would have done anything. Sia was my eldest, my helper. She was a pillar of this family.”
Sierra Leone regularly posts the worst child and maternal mortality rates in the world. Since its civil war ended in 2002, aid has poured into the country, inspired in part by the UN millennium development goals, targets for the reduction of emblematic indicators of poverty. But aid usually comes with conditions attached—like the fees that priced Sia out of antenatal care. These fees are part of development orthodoxy, espoused for over 20 years by the World Bank and agencies like Unicef and the World Health Organisation (WHO).
I walked down through the slum from Mabinti’s house to the clinic. It was very quiet. Four pregnant women gossiped in the sun as they waited to be seen. On the ward, only one of the eight beds was occupied. In the office of Albert Vandy, community health officer, a yellowed sheet pinned to the wall gave the health statistics for Dwarzak Farm: it said three in every 20 children born in the valley die before the age of five.
I asked Vandy about Sia’s death, which he hadn’t heard about. “No one is refused care,” he said. “Any fees are according to a person’s ability to pay.” But there is a big incentive to extract fees from women as they are vital to the clinic’s running costs, though Vandy said he didn’t use them—as some clinics do—to augment salaries. (Unicef subsequently told me they had no objection to the fees—“the important thing is that there is a clinic with trained staff and the right drugs.”) Vandy earns 144,000 leones (£25) a month, the nurses 120,000 (£20): the worst rates for health staff in Africa.
In the yard stood the clinic’s ambulance, a Land Cruiser. Through its topcoat of orange dust you could make out the logos of the UN Population Fund and Japan’s Maternal Mortality Reduction Project. No one could use it, Vandy said, unless they paid 25,000 leones (£4) for fuel. What was the local maternal mortality rate? “We don’t know,” he said apologetically. “So few of them are reported to us.” I asked him why he worked here, when he could earn five times as much working for an NGO. “I want to serve my nation,” he said.
***
Ten years ago this May, I went to Sierra Leone to report on the despatch of a small British taskforce of paratroopers and special forces to the country. Brigadier David Richards (now chief of the general staff) was in charge. His task was to bolster a UN peacekeeping force on the point of losing control of Freetown to the rebel militias who had taken most of the country. There was no strategic or commercial interest, and not much from the British public either. It was new Labour’s “foreign policy with an ethical dimension” in action—and it worked; in fact, it may have been the only successful military intervention by a colonial power in one of its former possessions in history. (While I was there in January, several people told me wistfully that they would like Tony Blair as their president.)
Robin Cook, then foreign secretary, promised to “rebuild Sierra Leone.” British civil servants were seconded to the shattered ministries and a retired chief constable from Manchester took charge of the police. A massive aid programme began: to this day, Sierra Leone receives more British aid money per capita than any other African country.
In 2000, the same year as Britain’s intervention, the UN agreed the millennium development goals. There are 15 of them to be achieved by 2015, and all are up for a review of progress this September. The fifth goal states that maternal mortality should be cut by three quarters by 2015.
Sierra Leone will come nowhere near meeting this goal. The country’s rate of 2,000 mothers’ deaths per 100,000 births (according to Unicef and the WHO) is perhaps the highest in the world. The sub-Saharan African average in 2005 was 900; in western Europe it is nine. In sub-Saharan Africa, 250,000 women die in childbirth every year, a third of them because of something as simple as a haemorrhage. In many countries childbirth is the most common cause of death for young women. Maternal mortality is reducing in sub-Saharan Africa but only very slowly—and of all the millennium development goals, the pledge to address the unnecessary death of mothers is furthest from fulfilment.
Death in childbirth is an unambiguous tragedy, and it touches the rich world’s conscience with ease. Across the world, premiers’ spouses (including Sarah Brown) have campaigned for maternal and child health. Perhaps as a result, funding for this area has soared—from £1.4bn to £2.3bn a year between 2003 and 2006, according to Oxfam. Spending on health in the developing world tripled in the noughties. So why are maternal mortality rates still so high?
There are two answers from development analysts. One is the fashionable “aid doesn’t work” line, promoted last year in Dead Aid, an influential book by Dambisa Moyo, a Zambian-born economist. This has been taken up by economists like Jagdish Bhagwati, and leaders like Rwanda’s Paul Kagame and former UN secretary general Kofi Annan. Moyo says that pumping money into countries without the systems to employ it properly fosters clientelism, dependency and corrupt and inefficient governments. She may have a point. In the past three years, Sierra Leone has received over $250m from Unicef, Britain’s department for international development (DfID) and the World Bank to tackle health—and its former health minister is awaiting trial on corruption charges.
But there is another argument expounded by the likes of Oxfam, which is about to publish a paper, “Aid in the 21st Century.” It holds that when aid fails it is partly due to the conditions and ideas that aid donors impose on recipient countries.
***
If aid can go wrong in many ways, the factors behind maternal mortality are just as numerous, starting with cultural issues. Women who have been circumcised are more likely to have problematic first deliveries. In some polygamous societies the value of a woman’s life is so low that families may not be prepared to pay for their healthcare. An “obstructed” labour may be seen as a sign that a woman has been unfaithful. All of these factors apply in Sierra Leone.
So do problems of infrastructure and personnel. To prevent deaths in childbirth, countries need midwives and surgeons, and the facilities to perform operations. The brain drain to the developed world, especially of nurses and midwives, has long hindered poor countries. Sierra Leone has just five gynaecologist/obstetricians and 95 midwives serving over 3m women. Six of the country’s 13 districts have no emergency obstetric facilities. As a result, less than 1 per cent of births are by caesarean, while the rate in societies with full access to healthcare is 8 or 9 per cent. Clearly, the women caught in that tragic statistical gap are likely to die in labour.
But in three other areas, attempts to improve maternal health (and infant survival) have faltered because of the ideological preoccupations of donor nations. These are, in ascending order of importance: dependence on traditional birthing systems, the withdrawal of funds for family planning and, most controversially, charging for access to medical services.
In the first area, attempts were made to deal with the lack of health workers by beefing up systems which had existed for centuries. In many countries, particularly in Africa, large sums were spent in training village “wise women” to be traditional birth attendants (TBAs). The results were disappointing. Too often, it was found that TBAs were less likely to seek professional help when births started to go wrong. According to Ibrahim Thorlie, chief consultant at Princess Christian Maternity Hospital: “If you want to reduce maternal mortality, there is no place for the TBA. When they try to deliver abnormal deliveries they create problems for us, and they cause deaths.” You cannot get modern survival rates without modern facilities.
The second area is pure ideology. While increasing health spending in Africa, the Bush regime withdrew funds from family planning, driven by the Christian right’s desire to promote abstinence. It is hard to assess the impact of this, but last year the UN calculated that 215m women worldwide do not have access to contraception. In Sierra Leone, it is thought that less than 4 per cent of women use it.
Ideology also drives what may be the most important factor: user fees. In 1987, the WHO and Unicef convened a summit in Bamako, Mali. At the instigation of the World Bank, African health ministers agreed to introduce point-of-use fees, as part of the “structural adjustment” plans being applied to developing countries to reduce state spending.
The user fees principle, known as the Bamako initiative, was supported by the key international players in health and donor countries like Britain. The World Bank estimated that the income from user fees could contribute 15-20 per cent of health budgets. Fees would also cut waste and “frivolous” use, especially of drugs. What you pay for, you use properly: the same argument that introduced prescription charges in the NHS.
By the mid-1990s, the Bamako initiative was a central plank of aid policy for public services. Most of the poorest countries implemented fees as they reformed their health services. World Bank and IMF loans for health were conditional on fees being introduced. By 2000, all but three African countries were officially charging user fees.
But as research on their effects started to emerge, opposition to their use grew. Some of the more radical aid organisations, like Médecins Sans Frontières, Oxfam and Save the Children, mounted campaigns against them. The UN and financial institutions remained adamant in their support, even as evidence showed that user fees were discouraging the poorest from using health clinics.
Fees also forced the poor to sell assets or borrow at exorbitant rates when ill. In the Democratic Republic of Congo, it was reported that fees had stamped out “frivolous” use of healthcare to the extent that the average person only visited a clinic once every 6.7 years. Across Africa, fees only brought in some 5 per cent of health budgets—far less than the World Bank promised. Meanwhile, health statistics failed to improve.
But the World Bank and other institutions would not back down. The authors of the Bamako initiative were still largely in office, and, as one analyst said, had “built their careers on user fees.” A spirited defence was mounted, which claimed that when a health system ran properly—meaning that donor funds were being spent on health workers’ salaries, rather than disappearing further up the chain—the system worked.
Unicef stood by user fees and has yet to disown them. In 2005, it produced statistics showing that if services improved, then usage of them increased. But it was clear from the UN agencies’ figures that in most countries, take-up was going down. In the more dysfunctional countries, fees had become the only means of keeping primary health clinics going—and a key element of the pay of those who worked in them.
Half the staff in some Freetown clinics are dependent on fees for their salaries. And when underpaid doctors and nurses have a direct interest in the collection of fees, things can go wrong very quickly. You don’t have to go far in Sierra Leone for an explanation of the country’s maternal mortality rates (of which everyone is deeply ashamed). It is that state clinics kill mothers because of the staff’s demand for fees. “They told my wife that she would have to have the baby cut out. They wanted a million leones. So she said she would trust in God, had the baby at home and she was fine,” said the restaurant manager at my hotel. Evidently, badly applied fees destroy people’s faith in state healthcare.
***
The rebellion against the user fees orthodoxy began in earnest in 2001. A few days before an election, the Ugandan president Yoweri Museveni announced a new policy of free healthcare for all. Rob Yates, now a senior health adviser at DfID, was then working on secondment at the Ugandan ministry of health. “I was a signed-up believer in user fees, and very dubious that the policy would work,” he says. But Yates was soon persuaded. After free healthcare started, attendance rates at primary healthcare clinics doubled. Half the take-up was from the poorest 20 per cent of people. “User fees were plainly excluding the poor—the very people the aid was designated for in the first place.”
Yates and others started to spread the news, armed with a telling amount of evidence. In Kenya, if you charged women just 50p for an insecticide-treated bednet (one of the most effective low-cost prophylactics against malaria) demand dropped 75 per cent. Uptake of deworming drugs—an important factor in child development—dropped 80 per cent if a small charge was applied. And in October 2005, the Bamako initiative received a fatal blow from a paper in the British Medical Journal. The study took epidemiological data from 20 African countries and projected what would happen if user fees were removed. The conclusion was that, each year, the lives of 233,000 children under five would be saved.
Taking note of Uganda’s success, in 2006 Senegal and Burundi promised to provide free healthcare at birth—despite continued opposition from international agencies. But donor countries began to change their minds. In a 2006 white paper, DfID announced support for countries who wished to remove user fees, soon followed by the EU.
By then, many of the analysts believed that dropping user fees could be by far the most cost-effective intervention on maternal and child health. Coupled with universal immunisation, it might mean that poor African countries could, after all, meet their millennium development goals on health. Almost 60 per cent of births in Burundi are now in health facilities—up from less than 25 per cent five years ago. Zambia, Burundi, Niger, Liberia, Kenya, Senegal, Lesotho, Sudan and Ghana have now dropped fees.
In April, Africa’s poorest country will make its move. With DfID’s support, Sierra Leone will drop fees for children under five and pregnant women. This will cost $91m in the first year—of which Britain is contributing about 10 per cent—and involves a 35 per cent increase in the health budget. But dropping user fees need not be so expensive. Uganda’s move increased the health budget by $1 per capita to $9 in the first year; Sri Lanka now provides free healthcare at $23 per head.
There are voices that urge caution. Dan Harris, a researcher at the Overseas Development Institute in London, observed the transition in Uganda. He says that soon after dropping fees in 2001, old problems resurfaced. “The huge increase in usage resulted in shortages of drugs and led to people having to seek them from private providers. Ultimately, the number of people having to make catastrophic payments for healthcare didn’t go down much.” Chris James was lead researcher on the BMJ paper and now works for the WHO in southeast Asia. He says: “There are risks in dropping fees too swiftly and you’ve got to make sure there is alternative funding in place, especially for health personnel.”
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Back in Freetown, the Princess Christian Maternity Hospital gleams in newly-painted white, like an ocean liner stranded on the grubby reef of the tumbledown city. Built in 1925, it is the only maternity hospital in the country. In a city where 1,000 women die in childbirth every year, you would expect it to be pretty busy.
But inside the compound, after negotiating a car park packed with 4x4s stencilled with the names of big NGOs and UN agencies, we enter the calmest state hospital I’ve ever seen—in Africa or Britain. Lounging around the admissions desk are three nurses. It is 4pm, and in this hospital of 150 beds they have received seven expectant mothers today.
Ibrahim Thorlie, the chief consultant, tells us that a caesarean costs 400,000 leones ($100) while an ordinary delivery costs 160,000 (£28): a month’s salary for a senior nurse. If a transfusion is needed, relatives have to give blood first. Is this why the hospital isn’t busy? “Of course!” says Thorlie.
“But we perform emergency caesareans every day free,” he says as we tour the wards. “We have to—there are families who just dump the mothers here and run away, because they are frightened of the debts. Women sometimes disappear when the operation is done.” In fact, community health officers told me that women have been refused treatment unless cash was provided first.
Thorlie acknowledges, “a lot of women die because they don’t want to come to hospital.” Worse perhaps than that, a lot of women die because they come too late—probably put off by the fees. For all its impressive facilities, the hospital has a dreadful record: in the first six months of 2008 9 per cent of the 900 or so mothers who gave birth here died. So what does he think of the plan to remove user fees: “We’re ready to make it work and do all that is provided but one thing is crucial. Our salaries must be augmented.”
The World Bank, chief ideological sponsor of user fees, now says it will not object if a country drops fees for healthcare. It is likely to bankroll the increases in health workers’ salaries in Sierra Leone. Funding healthcare remains a hot topic of debate. The big medical agencies now favour forms of health insurance, but that is only likely to work in places with good health services. There are more radical ideas around, especially in areas like infant health. Grants are given to expectant mothers in some Indian states to spend on any aspect of care; Mexico has done the same. In parts of Sierra Leone, the authorities have started fining women if they don’t give birth at clinics. Oxfam proposes that maternal mortality rates be seen as the key indicator of a country’s performance, rather than the numbers of health workers or per capita spend.
Most important of all, Rob Yates pleads that in future we look for evidence of whether rules will work before imposing them on poor countries. “This process did not seem to happen in the late 1980s,” he wrote in the Lancet. “We should have known that taking money from poor people when they are sick is not a good idea.” Sia Brima could have told us that too.
