As Mali announces a free healthcare initiative, can Sierra Leone’s example help?

As healthcare reforms aimed at reducing newborn and maternal mortality in Mali are announced, what can be done to ensure they succeed?


Maternal and newborn mortality rates in Mali are amongst the worst in the world – according to UNICEF, Mali ranks ninth among the countries with the highest newborn mortality rates. For every 1,000 babies born in the country in 2016, 36 died before the end of their first month. While numbers of maternal deaths have halved in the two decades between 1995 and 2015, significant challenges still remain for Mali in achieving progress against the third Sustainable Development Goal.

In light of these challenges, it is important to acknowledge the substantial health systems reforms announced last week by the Government of Mali. The initiative aims to upscale the access to healthcare services for the most vulnerable groups, including pregnant women, newborns, children, and adolescents. Starting from 2022 across the country, Mali will provide free healthcare for pregnant women and children under five, as well as offer free contraceptives and increase the number of community health workers available to help Mali’s 18 million people.

While people don’t access healthcare for many demand- and supply-side reasons in Mali, there is no doubt that high user fees in healthcare represent a critical barrier to accessing health services. A recent pilot programme, which ran in a semi-urban area of Mali’s capital Bamako, showed that easing the access to healthcare for mothers and infants helped to substantially reduce infant mortality rates.

How to turn this political drive into a real success?

A lot has been learned about how to turn this reform into success, not least from Sierra Leone, where key lessons have focused on the need to give the health system time to prepare. The removal of a major demand-side barrier – user fees – unsurprisingly leads to a great increase in demand, as women and child come to facilities that had previously been financially impossible. For the supply-side to meet this additional demand, systematic strengthening is necessary. This means:

  • More money must be allocated to healthcare to deal with the increased need in drugs, health workers, and commodities. A health financing strategy is crucial to support the budgetary needs. Conducting a fiscal space study could help the Ministry of Finance and donors keen on macro-economic health indicators realise that the user fees removal will not have a drastic impact on the budget (as indeed user fees bring little resources to national budgets), as these can be replaced by much more progressive forms of financing, such as corporate taxation.
  • More health workers will need to be distributed across the country to make sure that they are able to cope with the increase in demand. In many countries where user fees removal happened, salary increases were negotiated to recognise the increased effort health workers had to provide to respond to the increased demand.
  • More drugs and commodities for the specific target groups will need to be bought and supplied – in other countries, donors supported this increase. Planning carefully for it and distinguishing between cost recovery and free drugs will be vital.

Learning from others

A prolonged civil war in Sierra Leone, which ended in 2002, left the country crippled and its health systems weakened. To improve the population health outcomes, the Government of Sierra Leone introduced the Free Health Care Initiative in 2010, abolishing health user fees for pregnant women, lactating mothers, and children under five years of age.

Key additional lessons that have come out of our evaluation of the free healthcare initiative in Sierra Leone also point to the need to:

  • focus on the quality of care from the outset, as otherwise the risk is that quality further decreases without resources;
  • invest in institutional development of the Ministry of Health to steward the policy and health system, avoiding parallel systems, and boosting planning and staffing capacity;
  • develop a health financing policy to ensure the removal of user fees is institutionalised in the long term; and
  • engage with communities to support transport to facilities, spread information about entitlements and the benefits of health services, and raise awareness of danger signs for women and children.

It is indeed a great news for Mali and we need more news like this if we are to help improve healthcare systems and boost access to healthcare services for everyone. It’s important to not get lost in the debate of ‘this is not affordable’ – it is, and it can be a success, provided that the Ministry of Health is given time and authority to prepare for it. Sierra Leone did it in eight months. And look at the impact it had!

Photo: KODAKovic/

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