Int Health 2015; 7: 400–404

doi:10.1093/inthealth/ihv024 Advance Access publication 23 April 2015

ORIGINAL ARTICLE

When free healthcare is not free. Corruption and mistrust

in Sierra Leone’s primary healthcare system immediately prior
to the Ebola outbreak
Pieternella Pieterse* and Tom Lodge

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Department of Politics and Public Administration, University of Limerick, Limerick, Ireland

*Corresponding author: Present address: Portryan Bridge, Newport, Co. Tipperary, Ireland.
Tel: +251 912 669 382; E-mail: pieternella.pieterse@ul.ie

Received 6 November 2014; revised 16 February 2015; accepted 17 February 2015

Introduction: Sierra Leone is one of three countries recently affected by Ebola. In debates surrounding the
circumstances that contributed to the initial failure to contain the outbreak, the word ‘trust’ is often used: In
December 2014, WHO director Margret Chan used ‘lack of trust in governments’; The Lancet’s Editor-in-Chief,
wrote how Ebola has exposed the ‘… breakdown of trust between communities and their governments.’ This
article explores the lack of trust in public healthcare providers in Sierra Leone, predating the Ebola outbreak,
apparently linked to widespread petty corruption in primary healthcare facilities. It compares four NGO-
supported accountability interventions targeting Sierra Leone’s primary health sector.
Methods: Field research was conducted in Kailahun, Kono and Tonkolili Districts, based on interviews with health
workers and focus group discussions with primary healthcare users.
Results: Field research showed that in most clinics, women and children entitled to free care routinely paid for
health services.
Conclusions: A lack of accountability in Sierra Leone’s health sector appears pervasive at all levels. Petty corrup-
tion is rife. Understaffing leads to charging for free care in order to pay clinic-based ‘volunteers’ who function as
vaccinators, health workers and birth attendants. Accountability interventions were found to have little impact
on healthworker (mis)behaviour.

Keywords: Corruption, Ebola, Health systems, Maternal and child health, Sierra Leone

Introduction On introduction, the initiative proved a success: the number

Sierra Leone emerged from a brutal civil war in 2002 with much of its
health infrastructure destroyed. Many doctors and nurses were either
killed during the conflict or had fled the country. During the first
post-war decade hospitals and clinics were rebuilt, but staff training,
management and oversight in the primary health sector were
badly neglected. An Amnesty International report in 2009
found that in most areas where it carried out research, [staff]
‘whether paid or unpaid, would unilaterally and illegally charge
fees and keep the money’,1 which created a healthcare system
that was often too costly for many Sierra Leoneans to access.
Infant, child and maternal mortality rates were the worst world-
wide.2,3 In April 2010, Sierra Leone introduced free healthcare for
pregnant and lactating mothers and children under five. This sig-
nificant (primarily donor funded) change of policy was designed
to improve access to basic primary healthcare.
of children who received care at primary healthcare facilities
increased 2.5-fold within the first year4 and child mortality rates
dropped from 217 to 158 per 1000 live births between 2010–
2013.5,6 However, the new system is not without serious short-
comings: Sierra Leone continues to have the highest infant and
maternal mortality rates in the world.7 Corruption scandals have
plagued the free healthcare initiative. Media reports on the contin-
ued charging by health workers for services that should be free, and
the diversions of drugs to private pharmacies or neighbouring coun-
tries, are common.8,9 Changes were introduced following calls for
better monitoring, and greater accountability within Sierra Leone’s
health sector.10 A tracking system was established to follow the
free medication from port to clinics.11 In addition, a substantial
number of community-based organisations started to carry out
health monitoring interventions, focusing on health sector account-
ability at community level. Field research presented in this paper

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International Health
examines the impact of four such accountability interventions in
the health sector.
Materials and methods
The field work, completed in May 2014, several days before Sierra
Leone’s first Ebola case was confirmed, focused on four different
community-based interventions with similar objectives: ‘to improve
the accountability of the health workers and the health system at
district level’. Intervention 1 and 2 provided awards for improved
service provision, while 3 and 4 focused on community–healthworker
dialogue.
Each intervention had a unique methodology:
1. The non-financial award programme was part of a rando-
mised controlled trial which compared this method to 3. the com-
munity monitoring with score cards intervention. Staff at selected
clinics were told of their health centre’s relative ranking compared
to other facilities in their locality (based on externally collected fa-
cility birth rates and infant, child and maternal mortality data) and
staff were encouraged to design and implement their own im-
provement plans. The health workers were told they could win a
non-financial award if their efforts showed improved rankings.
At the end of the interventions, updated rankings were compiled
(using exit data) and participating clinic staff received a certificate
and a clock as a reward.
2. The participatory monitoring and evaluation programme
brought health workers, district health authority staff and com-
munity members together to design a rigorous check list that
ascertained to what extent clinics ‘implemented the free health-
care policy in an accountable manner’. Each year clinics were
assessed and the best small, medium and large primary health-
care facility in the district were awarded with a motorbike (for
the clinic) and a cash prize, as well as much public recognition.
3. The community monitoring with score cards method brought
together community representatives and health workers to hold
three facilitated dialogue sessions (within 6 months). These ses-
sions focused on what behaviour changes both healthcare staff
Table 1. Research sites, number of clinic visited and methodologies used
Date Location Accountability intervention method
Sept 2012 Kono Mixed methods
Kailahun Participatory monitoring and evaluation
Nov 2013 Kailahun Participatory monitoring and evaluation
Tonkolili Non-financial award
Tonkolili Community monitoring with score cards
Tonkolili Control group
May 2014 Kono Mixed methods
Total number of clinics included in this research:
NA: not applicable.
and community members could make to improve the commu-
nity’s basic health indicators (which were collected by the facili-
tating NGO and presented using score cards).
4. The mixed methods intervention used similar dialogue ses-
sions between community representatives and health workers
using a method called ‘quality circle’, whereby health service sat-
isfaction was assessed conducting short surveys among citizens
in each target community. In this case the community represen-
tatives were predominantly Facility Management Committee
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members, pre-existing groups that provide community-based
oversight at each peripheral healthcare unit in Sierra Leone
(these groups were established country-wide in 2012, though
many became inactive soon after their establishment). The
implementing NGO furthermore trained the Facility Management
Committee members to collect data on patient numbers and
facility deliveries, and the programme also had a radio listening
component, budget literacy training, and a construction project
at each target clinic, all designed to reinforce community-health
worker relationships, hence the name ‘mixed methods’.
Table 1 provides an overview of the scope (number of clinics
targeted) and the locations where each intervention took place.
In Tonkolili, two different accountability methods were implemen-
ted in selected clinics, which were part of a randomised controlled
trial, comparing the efficacy of those two methods.12 In Tonkolili
six clinics were included as a control group for this study.
Data collection
One-to-one interviews were conducted with the ‘health worker in
charge’ at most of the 35 clinics. Close to each of the selected
clinics, focus group discussions were held with 6 to 12 women
who were pregnant, lactating or mothers of children under five
(i.e., within free healthcare target group), all of whom reported
using the selected clinic. A total of 25 key informants were inter-
viewed, including ‘volunteers’ who worked at clinics, members of
the district health management teams, employees of the Ministry
of Health and Sanitation in Freetown, and staff of donor agencies
and NGOs. For all interviews, the discussions focussed on the issue
Amount of target Number of clinics
clinics per visited for research
intervention
NA 4 (pilot)
NA 2 (pilot)
80 8
23 6
23 6
23 6
10 9
35
401
P. Pieterse and T. Lodge
of accountability in the health sector and the impact of the
accountability interventions. The interviews and focus group
discussions were held using interview guidelines, which were
piloted during a pre-research visit, and all the data was analysed
using qualitative data analysis software NVIVO10 (QSR Inter-
national, Doncaster, Victoria, Australia).
Results
During the field research, ‘paying for services that should have been
free’ quickly became a proxy indicator for ‘accountability’. While
‘acting accountably’ is obviously much more than ‘not charging
for check-ups or free medication’, focus group participants clearly
identified this problem as their number one grievance. Using the fre-
quency with which this problem was raised within focus groups as
an indicator, approximate success rates of the four accountability
interventions in reducing illegal charging is illustrated in Figure 1.
During each focus group discussion issues such as absenteeism,
friendliness of staff, and the effort healthcare staff made to serve
each patient, were also discussed. Triangulation questions were
used to verify the veracity of allegations made against health
workers who were said to have charged patients for health services
or medication that should have been supplied for free.
The fact that in 24 out of 35 clinics focus group discussions
highlighted ‘charges that were levied for free services’, suggests
that this problem remains common. Similar observations were
made by other researchers, including Stevenson et al, who
suggest that at least 20% of the patients (using exit interviews
after clinic visits) were charged for free services.13
The patients’ perspective
Empirical evidence suggests that charges often increased grad-
ually since the Free Healthcare Initiative’s inception in April
2010. Several interviewees described how routine health worker
post rotations often sparked increased fees, with newly arrived
health workers introducing payment for free care. Multiple inter-
viewees in different locations explained that health workers
re-introduced charges for all medicine after declaring that the
free medicine had run out. This complaint was common, despite
Figure 1. Number of focus group discussions in which the problem of
‘charges levied for free healthcare’ was discussed, by type of accountability
intervention. M&E: monitoring and evaluation.
402
the fact that since the free healthcare was introduced, quarterly
deliveries of free healthcare medication are made to every
public primary healthcare centre and these deliveries are sup-
posed to be witnessed by several community representatives.
The focus group discussions showed that the charges for
primary health services varied: patients were most commonly
charged for medicines such as infant paracetamol or cough
syrups. Reported service charges ranged from a small fee to
have a baby weighed, or for ante-natal check-ups, to payments
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for consultations and even vaccinations. Many women reported
paying for the free card that recorded their ante-natal visits or
their baby’s vaccination records.
Confusion surrounding the supply and cost of medicine was
common. Many interviewees complained that certain free medi-
cine ‘is always out of stock, but it can usually be purchased
from the cost-recovery cupboard’. The 2011 Amnesty Inter-
national report which highlights the continued charging for free
healthcare echoes this complaint.14 It evidently created suspi-
cions among patients, who admitted not always believing
health workers who told them that there was no free medicine
left. However, the majority of women added that they would
not dare challenge their local health workers.
The effects of the accountability interventions were varied: the
two awards interventions resulted in vastly differing outcomes. In
Kailahun, where participatory monitoring and evaluation was
used (linked with the award of a motorbike and cash prize for
best performing clinics), only one focus group out of eight men-
tioned women being charged for free care, while five out of six
focus groups mentioned charging in the area where non-financial
awards were offered. Health workers who participated in the non-
financial award project explained during interviews that they had
tried to be absent less and several reported going on outreach to
vaccinate children in remote communities more often, but none
spoke of introducing changes to their fees.
Where interventions focused on dialogue between health
workers and either community representatives or Facility Manage-
ment Committee members, the researcher interrogated partici-
pants of these dialogue sessions either within the focus groups
or during separate interviews. The large majority expressed disap-
pointment about promises made, but not kept, by health workers
during the dialogues. Charges levied for free medicine and care
was reported as a problem in all six focus groups in the commu-
nity monitoring area, and in eight out of nine focus groups in
Kono, where the mixed methods approach included health
worker–Facility Management Committee dialogues.
The health workers’ perspective
The most common general complaint from the health workers
was related to ‘being unable to incentivise the volunteers who
work at the clinic’, as one nurse in Tonkolili explained.
Health workers interviewed about the accountability pro-
grammes all felt that the projects were useful and had improved
their behaviour somehow. However, according to the focus group
discussions with clinic users, only one out of the four interventions
seems to have contributed to positive change: in Kailahun, where
the participatory monitoring and evaluation method was linked to
significant rewards for improved care practices at the clinics,
health workers and focus group participants could list a range of
improvements since the accountability intervention started:
International Health
clinics opened promptly and stayed open throughout the whole
day, staff were friendlier, hand washing and toilet facilities were
improved and price lists for cost-recovery drugs were displayed.
During only one out of eight focus groups was any kind of charging
mentioned, and this was related to a traditional birth attendant
who helped at a clinic.
The other interventions did not achieve such behaviour
change; in the area where non-financial awards were offered,
health workers had been asked to choose for themselves which
improvements they wanted to make, and as a result, only minor
changes were reported by all health workers.
Where dialogue with community members or Facility Manage-
ment Committee members took place, the impact seemed least
impressive. Most health workers reported appreciating these ses-
sions but reported using them to tell the local women to come to
the clinic more promptly during labour, for vaccinations, ante-
natal care or to help clean around the clinic area. Focus group par-
ticipants and NGO facilitators explained that when health workers
were accused of illegal charging during these dialogues, they fre-
quently brushed these accusations off with statements such as
‘the community doesn’t understand the rules of free health-
care–they bring me children who are over 5 years old and not
entitled to free care’ or ‘I treated the patient with cost recovery
medicine and charged her for it, because the free medicines
were out of stock and I had to save her life.’ Few, if any, admissions
or apologies for wrongly charging for free care seem to have been
obtained during the dialogue sessions.
The issue of oversight was discussed with all health workers,
who received between one and three visits per quarter from
their local district health management teams. Supervisors were
said to check stocks of medical supplies and ledgers that are
kept by healthcare staff to record the number of patients they
treated daily. However, no evidence could be found to suggest
that complaints about charging for free healthcare were ever
addressed and no disciplinary cases were recorded in the three
districts where this research was carried out.
Discussion
This paper highlights the mistrust of health workers that already
existed in rural communities, well before the Ebola crisis. Compar-
ing the four accountability interventions, it can be noted that all
interventions achieved some (albeit limited) behaviour change,
ranging from reducing absenteeism to health workers making
more regular vaccination visits to remote communities. However,
it was evident that only one methodology managed to achieve a
reduction in the levying payments for free care. The intervention
that offered a substantial reward and a reasonable chance of
winning it (every year for four consecutive years three motorbikes
were awarded among 80 competing clinics), clearly motivated a
significant number of healthcare staff to curb informal charges.
The district health authorities’ involvement in both the survey
design and the award ceremonies may also have contributed to
the programme’s success.
So why did the other interventions not work well in Sierra
Leone? There appear to be a number of reasons for this. Health
workers’ position of power within communities should not be
underestimated, and neither should it be forgotten that charging
for primary healthcare was the norm in Sierra Leone until 2010.
Studies have shown that in other countries, peer pressure
applied through social accountability interventions had a signifi-
cant effect on health worker behaviour and increased the trust
in regular health facilities (data showed an increase in the attend-
ance of public facilities in favour of private suppliers after social
accountability interventions).15 This study shows that social pres-
sure applied through repeated dialogue sessions between health
workers and the communities they serve were much less effective
in Sierra Leone. It may be that the social contract between service
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provider and service user simply hasn’t recovered from the stres-
ses of the civil war. In addition, Sierra Leonean health workers
operate with a certain level of impunity, as disciplinary procedures
are unheard of in the primary health sector: charging for free care,
misconduct, absenteeism, and other unethical behaviour in
health facilities goes routinely unpunished. None of the interven-
tions examined for this study included feedback loops that linked
‘a lack of promised behaviour change on the part of the health
workers accused of petty corruption’ with more formal disciplinary
procedures, indeed some of the interventions barely interacted
with district health officials at all.
The problem of charging appeared to have been exacerbated
by the more structural problem of staff shortages, which
seemed to necessitate clinics’ use of unpaid ‘volunteers’. The lit-
erature on Sierra Leone’s healthcare system before the introduction
of the Free Healthcare Initiative notes multiple problems regarding
unpaid staff.16,17 Amnesty International’s 2009 report points out
that ‘ …the number of people working within the health system
without receiving any salary at all lead to individual health care
staff charging patients for services directly’.18
At the introduction of the free healthcare, ghost workers were
removed from the payroll and over 1000 new health workers were
hired. However, President Koroma himself admitted that this led
to the reduction in the number of health facilities ‘with only one
health care staff from 59% to 33%’.19 Despite further recruitment
in the health sector, it is clear that understaffing remains a signifi-
cant problem, and relying on a cadre of ‘volunteer’ staff is clearly a
common coping strategy in many understaffed clinics. Signifi-
cantly, several Ministry of Health and Sanitation staff (at district
and national level) tacitly agreed that health workers could not
manage rural clinics if they did not have at least two or three
‘volunteers’. Everybody, including many patients, agreed that
‘nobody could work for nothing’, and this, for many interviewees,
justified the illegal charging to pay for the ‘volunteers’.
Limitations of this study
Firstly, the four interventions studied varied significantly in scope,
size of budget and levels of staff and expertise deployed to imple-
ment each methodology; this study should therefore not be read
as a like-for-like comparison of the relevant methodologies, rather
a series of comparative case studies, in which each case focused on
a different methodology, implemented under a unique set of cir-
cumstances. Secondly, the scale of the alleged ‘charging for free
healthcare’ was much larger than expected. Future studies could
further explore the links between informal charges and a lack of
trust in healthcare workers, which became evident during the
empirical study. Finally, it is assumed that the Ebola epidemic has
had a significant impact on the sustainability of the studied inter-
ventions. With so many health workers in Sierra Leone affected
by the epidemic, it is impossible to know whether any of the
403
P. Pieterse and T. Lodge
behaviour changes achieved during the implementation of the ac-
countability interventions have survived the past 12 months.
Conclusions
The field research examining the success of accountability inter-
ventions in Sierra Leone’s health sector suggests that the majority
of the interventions only achieved limited improvements. One
intervention, which offered a significant financial incentive for
more accountable behaviour and was well linked to the district
health authorities, was the only project that was able to curb
charging for free healthcare. It appears that neither the promise
of a non-financial award nor the social pressure applied during
a serious of dialogue sessions between health workers and clinic
users was successful in tackling this problem.
The research was carried out up to several weeks before it
became obvious that people in the Sierra Leonean districts border-
ing Guinea and Liberia had started to contract Ebola. During the
focus group discussions a general distrust of health workers was
evident. The large majority of focus group participants explained
that the care provided since the introduction of the free healthcare
was rarely completely free for women and children under five, al-
though many agreed that the system was better than before.
While it is impossible to quantify how much the pre-existing
lack of trust in Sierra Leone’s healthcare staff may have exacer-
bated the spread of the Ebola virus, this study shows that the
much cited mistrust in health facilities should not only be attribu-
ted to patients’ fear of contracting Ebola in healthcare facilities.
Trust in health workers was clearly something that had not yet
been regained after many decades of underinvestment, under-
staffing and a poorly implemented free healthcare initiative. As
academics start to piece together the puzzle of circumstances
that led to the spiralling out of control of the current epidemic,
it is hoped that lessons can be learned from the context in
which, what renowned Ebola expert Peter Piot called ‘Ebola’s
perfect storm’20 was able to take hold.
Authors’ contributions: PP conceived the study, designed the study
protocol and carried out the field work in Sierra Leone. PP also carried out
the analysis and interpretation of the data, and drafted the manuscript.
TL commented on the manuscript for intellectual content. All authors
read and approved the final manuscript. PP is the guarantor of the paper.
Acknowledgements: The authors thank all the interviewees for their time and
acknowledge the support from Christian Aid Ireland (and its implementing
agencies SEND Foundation and Network Movement for Justice and
Development) and Concern Worldwide (and its implementing partners
OPARD, COBTRIP, CIDA and Pikin-to-Pikin) during the field research in
Sierra Leone.
Funding: None.
Competing interests: None declared.
Ethical approval: Approval obtained from the University of Limerick,
Faculty Research Ethics Committee, decision code ‘FAHSS REC 649
Improving social accountability interventions in healthcare’.
404
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