More than 2 years have passed since Sierra Leone granted pregnant women, new mothers, and young children free health care, but their needs often remain unmet. Amy Maxmen reports.

Marta Amara's water broke on Nov 5, 2012. Community members carried her in a hammock to the nearest health facility, nearly 10 km away from her village in rural Sierra Leone. A baby's tiny arm emerged soon after she arrived, but not its head. Realising that the birth would be too complicated in a centre ill-equipped for surgery, staff urged her to pay a taxi driver the equivalent of US$29 to take her on a 2-hour trip to the district hospital in Kenema. They arrived after nightfall to discover a hospital lacking electricity. Amara then paid for transportation to an emergency clinic operated by Médecins Sans Frontières (MSF). By the time she arrived, her baby was dead and she was internally bleeding from a hole in her uterus. MSF obstetrician and gynaecologist Betty Raney stitched the wound, which saved Amara's life but rendered her infertile. “Women and children die because of delays in care”, Raney says. She sees preventable deaths daily, despite the country's 2-year-old policy for free health care for pregnant women and children younger than 5 years.

To international applause, President Ernest Bai Koroma announced the free health-care initiative on April 27, 2010. Koroma's intention was to reverse Sierra Leone's position as one of the world's most deadly places to give birth and to be born. World Bank statistics show that one woman dies in childbirth for every 112 births in Sierra Leone. That rate is 2·5 times higher than in nearby Ghana, 42·4 times higher than in the USA, and 222·5 times higher than in Sweden, where the rate is one death per 25 000 births. Furthermore, nearly one in five children born in Sierra Leone dies before they reach 5 years of age.

Amara's experience reveals a number of the initiative's shortcomings: she arrived at the clinic hours after she started labour; she paid for travel when ambulances should be provided for free; and the hospitals were not prepared for surgery. Certainly, health care is better than it was. More than five times as many children are treated for malaria with the recommended artemisinin now than in 2008, according to household surveys. And now that cost is no longer a barrier in a country where 74% of the population lives on less than $2 per day, health-care use has increased by 60%.

However, the rise in health-care demand has exposed which components of the fragmented health-care system need urgent repair, and which require longer, more thorough changes. Progress has been incremental, but international donors including the UK's Department for International Development, and aid organisations such as MSF, remain committed to helping the government lift Sierra Leone from the rubble it was left in after their 11-year blood diamond war. “Today we see fantastic improvements in health and sanitation”, says Yvonne Nzomukunda, MSF's medical coordinator in Sierra Leone, “but compared to other countries in the region, we still lag far behind”.

When the free health-care initiative launched, the government teamed up with UNICEF to procure and distribute drugs intended for women and children. The inefficient network through which drugs were ordered and distributed would need to be rebuilt to meet an increased demand. At some point between the port (where drugs arrive), the warehouses (where they are stored), and hundreds of health-care facilities, an uncertain percentage of medicines were being lost or illegally sold for profit. As a result, UNICEF froze drug distribution in May, 2011, while they investigated the leaks and created a series of checks to track drug movement. By November, 2011, the drugs were flowing across the nation again.

Substantially large and mysterious leaks are no longer a problem, but drugs still go missing. In September, 2012, two containers of free health-care supplies, including antibiotics, were stolen from the port, and auctioned away for money. On hearing the news, President Koroma appointed a team to investigate. They retrieved one container, but the other remains at large. In addition, a bulletin in June, 2012, from the Health For All Coalition, a health advocacy organisation in Sierra Leone, reveals that although the main drug warehouses in Sierra Leone received the correct amount of drugs, 26% of them never reached the health facilities they were destined for. Drugs might not have reached their final destinations because delivery jeeps were broken or had no fuel, or because no one was waiting to receive them, explains Roeland Monasch, a UNICEF representative in Freetown.

Nurses attend a patient at the Princess Christian Maternity Hospital, Freetown Copyright © 2013 Amy Maxmen

Monasch adds that the situation is improving. For example, the government has got better at forecasting what drugs people will need far in advance. And this year, the Ministry of Health and Sanitation plans to add another layer of accountability by installing a toll-free number for patients to report when the clinic has no drugs or if they were wrongly told to pay for them. Also this year, Crown Agents, a British company specialising in procurement systems, will help the government establish a national centre devoted to obtaining drugs. Monasch says the goal is to establish a stable system so that the government can take it over by 2015 once Sierra Leone's GDP increases through mined iron, diamonds, and gold. “In the next few years, the mining sector should have boosted the country's finances, and we want to ensure that when the time comes, a system is in place for the government to take over”, he says. “In the meantime, we are trying to ensure that women and children are assisted right away.”

Diagnostic capacity must improve as well. By June, 2012, 97% of all health facilities could test patients for malaria, half for HIV, and just 13% could test for tuberculosis, in a country with one of the world's highest rates of the pulmonary disease.

If lack of drugs and diagnostics are the tip of the iceberg, poor infrastructure resides a layer below. Many villagers cannot reach hospitals because of tumultuous rivers or flooded dirt roads. Furthermore, a lack of electricity, running water, and blood for transfusions frequently makes emergency care unreliable for children with untreated malaria or severe diarrhoea, and for mothers in need of caesarean sections. September, 2012, government bulletins report that only five of 12 district hospitals and about 20% of selected community health centres were prepared to provide emergency obstetric and neonatal care, which still represents an improvement over zero in 2008. Nationwide, 15 hospitals have functional blood banks, up from four in 2008. However, the banks often lack blood.

For Samuel A S Kargbo, the director of reproductive and child health in the Ministry of Health and Sanitation, electricity and blood blanks are a top priority. Before health care was free, so few mothers visited hospitals that a night-time need for electricity was not apparent, he says, and blood could often be provided by a patient's relatives. Once the allure of free health care increased demand, the deficiencies of the old system surfaced. “Now they come at night, and we are not prepared”, Kargbo says. Because the infrastructure for electricity cannot sustain 24-hour use in many districts, Kargbo is delighted with a November, 2012, donation of 42 solar power systems made by WE CARE Solar, a solar energy charity in Berkeley, California. Kargbo plans on pushing for more solar power this year.

Another simple success comes in the form of “waiting houses” provided by MSF at nine health facilities in the Bo district. Mothers are encouraged to sleep at these no-frills houses as their due date approaches, to reduce the painful journey that many make by motorbike or hammock to a hospital. This measure, plus an emergency line to call an MSF ambulance, helped the organisation reduce maternal mortality by 61% in Bo, according to their report released in November, 2012.

A deficiency in skilled labour will take several more years to remedy. “If all of the foreign doctors working here went away”, Kargbo says, “we couldn't sustain the hospitals”. During the war, between 1991 and 2002, doctors fled the country in search of safer, paying work environments and medical schools fell to waste. The Ministry of Health and Sanitation has teamed up with the Ministry of Education to encourage more students to enter medicine. The government also increased the salaries for doctors and nurses, and opened secondary schools to train more midwives. Enrolment is up, but experienced and motivated workers remain rare.

Finally, Sierra Leone may never meet the UN's Millennium Development Goals for reduced maternal and infant mortality if they do not curb some cultural norms. Namely, two of the top risk factors for a dangerous birth—pregnancies less than 1 year apart and teenage pregnancy—remain common. Sallay Sama, a nurse at the Princess Christian Maternity Hospital in Freetown, says she finds it difficult to relay the importance of family planning. “The poorer mothers want a lot of children so that some of them will survive to care for them”, she explains. In addition, she says unmarried pregnant girls between ages 12 and 18 years account for a high proportion of maternal injuries and mortalities at the hospital.

Contraceptives are offered for free to new mothers under the free health-care plan, but uptake remains low. Only 6% of married women aged 15 to 49 years take the pill or other contraceptives in Sierra Leone, compared with 17% in nearby Ghana, 73% in the USA, and 84% in the UK. In response to high rates of teenage pregnancy, Kargbo says the government has begun to educate teenage girls in school about their right to say “no” to sex.

Updated statistics on maternal and childhood mortality will not be available until 2014. An astounding turnaround may be too much to ask. The road ahead will be long, but the risks of giving up now would be devastating. “Our country is very young, and there are many things that have set us back”, Kargbo says. “When we go two steps forward, we're still just moving one step at a time.”