A Promise Kept: How Sierra Leone's President Introduced Free Health Care in One of the Poorest Nations on Earth, 2009

A PROMISE KEPT: HOW SIERRA LEONE’S PRESIDENT INTRODUCED FREE HEALTH CARE IN ONE OF THE POOREST NATIONS ON EARTH, 2009 - 2010

SYNOPSIS When Ernest Bai Koroma assumed the presidency of Sierra Leone in 2007, he promised to run his government as efficiently as a private business. A few years earlier, a brutal 11- year civil war had ended, leaving an estimated 50,000 dead and an additional two million displaced. The effects of the war gutted the government’s capacity to deliver basic services. Koroma launched an ambitious agenda that targeted key areas for improvement including energy, agriculture, infrastructure and health. In 2009, he scored a win with the completion of the Bumbuna hydroelectric dam that brought power to the capital, Freetown. At the same time, the president faced mounting pressure to reduce maternal and child death rates, which were the highest in the world. In November, he announced an initiative to provide free health care for pregnant women, lactating mothers and children under five years of age, and set the launch date for April 2010, only six months away. Working with the country’s chief medical officer, Dr. Kisito Daoh, he shuffled key staff at the health ministry, created committees that brought ministries, donors and non- governmental organizations together to move actions forward, and developed systems for monitoring progress. Strong support from the center of government proved critical to enabling the project to launch on schedule. Initial data showed an increase in utilization rates at health centers and a decline in child death rates.

Michael Scharff drafted this case study on the basis of interviews conducted in Freetown, Sierra Leone and London, U.K., in September and October 2011. Case published February 2012. See related cases, “Turning on the Lights in Freetown, Sierra Leone: Completing the Bumbuna Hydroelectric Plant, 2008-2009” and “Delivering on a Presidential Agenda: Sierra Leone’s Strategy and Policy Unit, 2010-2011.”

INTRODUCTION mothers and children under five years of age in In March 2010, Sierra Leone’s president, less than a month, but the tour revealed that Ernest Bai Koroma, undertook a nationwide repairs to health centers were behind schedule. helicopter tour to evaluate progress on a national The delays threatened to derail plans. health-care initiative. The government planned The president convened a meeting at his to launch free care for pregnant women, lactating home with his advisers, health staff and the heads

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Michael Scharff Innovations for Successful Societies of donor groups, and threatened to fire everyone if projects through ministries. With the help of the delays continued. Ultimately, he did not fire Victor Strasser-King, a Sierra Leonean who anyone, but to those seated in his living room, the served as head of the group, Koroma’s threat highlighted the president’s personal government was just months away from finishing investment in the project and his commitment to the dam project. success. Just six months earlier, most people in A series of events created an opportunity not the room that night would never have imagined only to take some of the lessons emerging from that Sierra Leone could organize free maternal the Bumbuna experience and use them to improve and child health care, at least not so soon—or that health care for women and children, but also to the main champion would be the president improve coordination at the cabinet level, in the himself. center of government. This case chronicles the When he came to office in 2007, five years innovations a reform team led by Dr. Kisito after an 11-year civil war left an estimated 50,000 Daoh, the chief medical officer in the Ministry of dead and two million displaced, the then 54-year- Health and Sanitation (hereafter referred to as the old Koroma, a former insurance broker, promised health ministry), put in place with the president’s to bring business efficiency to his government. help. The case demonstrates how the innovations One of his first priorities was to develop improved both cabinet effectiveness and made Sierra Leone’s second Poverty Reduction Strategy progress in providing better health services. Paper, a template for national development, Between August 2009 and April 2010 when the drafted on the basis of conversations with president launched the program, the team created government officials, national civic leaders and aid structures and processes for defining priorities, donors every three years. The strategy paper, generating action, monitoring progress and which Koroma labeled his “Agenda for Change,” coordinating efforts by ministries and agencies— emphasized progress in energy, agriculture, all of this in a government that had few highly transportation, education, health and other social trained or experienced managers or technical staff. services. Koroma focused on the needs of The team also developed a creative way to engage ordinary citizens. and coordinate donor involvement. With government capacity low in the wake of the war, Koroma found it difficult to make THE CHALLENGE progress on his agenda. The war had destroyed As 2009 began, the urgent need to improve much of the country’s infrastructure and displaced maternal and child health care in Sierra Leone government workers, leaving ministries and was clear, but the country seemed poorly departments without skilled employees. In positioned to respond. Sierra Leone ranked worst August 2009, Koroma was striving to complete in the world for both maternal mortality and the Bumbuna hydroelectric dam, which was to infant mortality. At the time, the risk that a provide the capital with its first reliable power woman would die during childbirth at some point source. The effort to improve electricity supply in her life was one in eight. One in 12 newborns had dragged on for years, beset by a lack of died within a year. Data showed that cost coordination among government ministries and deterred women from seeking care or bringing contractors. In an attempt to overcome capacity their children for treatment, and there were few problems in the ministries, the president grounds for optimism. In 2002, the health established a special advisory group that provided ministry had attempted to launch a free health- him with strategic advice on how best to drive key care program without first addressing ! © 2012, Trustees of Princeton University Terms of use and citation format appear at the end of this document and at www.princeton.edu/successfulsocieties

Michael Scharff Innovations for Successful Societies fundamental challenges to the health sector, such Possibly to counter the whispers in the ministry as the low salaries and lack of medical supplies. corridors, the health minister called an emergency The initiative quickly fizzled. In 2005, Sierra meeting in the first week in August. He gathered Leone had eliminated user fees yet again, but the his senior staff and about a dozen donor government, weakened by the prolonged conflict, representatives, and told the group that he wanted could not enforce the law. Informal fees charged to make health care free for pregnant women and by health workers replaced formal fees, and the children. law did not provide for free medicines, which His proposal attracted enthusiasm from discouraged people from seeking care. international aid agencies and non-governmental Despite the setbacks, advocacy groups organizations. However, worried that a flood of continued to press for action. At the same time, visitors could inundate health centers if the policy makers in other parts of the world had initiative were not properly planned—and well begun to worry that African countries would fall aware of past failures to launch free care— far short of reaching Millennium Development international experts urged the minister to delay Goals—concrete targets, including improvements implementation until the ministry formulated a in child and maternal health, that U.N. member strategic plan. states agreed to achieve by the year 2015—and The health minister called on Daoh to help urged free health care for women and children. create a plan of action. Daoh had been a clinician They wanted Sierra Leone to join with Burundi, in Sierra Leone in the 1980s and rose through the Zambia and other countries in abolishing user ranks at the health ministry, eventually becoming fees. head of reproductive health and then chief When it came time to sign performance medical officer. He was an invaluable leader contracts with his ministers in early 2009, within the ministry. “Dr. Daoh made the President Koroma, sensing the importance of the difference in the ministry,” recalled Francesca issue, put making health care free for pregnant Pacitti, a former adviser with the Africa women, new mothers and young children in his Governance Initiative (AGI), a nonprofit health minister’s contract. The actual wording in organization headed by former U.K. Prime the contract, however, included few specifics on Minister Tony Blair. “He would have his team in how to deliver on this charge. Many other his office every morning at 8 a.m. You couldn’t priorities competed for the president’s attention, do something like free health care just from the and a year and a half after he assumed office, the top. You needed people in the ministry.” president still had focused little attention on the Daoh gathered the heads of the health issue. ministry’s eight directorates and sought counsel A series of events created an opportunity to from development partners. attempt, yet again, a free health-care program. In These developments attracted the notice of the summer of 2009, Koroma’s health minister, others. Following the health minister’s Sheku Tejan Koroma, who was not related to the announcement, the international community president, found himself in hot water. The hoped that Koroma would use the meeting of the country’s independent anti-corruption United Nations General Assembly, scheduled for commission, which the president established upon late September 2009, to formally announce the taking office, had started to investigate whether program. Although Daoh and his team had Tejan Koroma had abused the powers of his office begun exploring details, free health care was not by steering contracts to business associates. yet policy, and advocacy groups continued to push " © 2012, Trustees of Princeton University Terms of use and citation format appear at the end of this document and at www.princeton.edu/successfulsocieties

Michael Scharff Innovations for Successful Societies for action. Just before the U.N. meeting, health ministry’s process, which meant that the Amnesty International published a report that ministry was often unaware of what drugs the declared Sierra Leone’s poor maternal and child World Bank was ordering. Another challenge health performance “a human rights emergency.” was that sometimes donors supported non- The president stopped short of making an official priority projects for Sierra Leone, and the projects announcement at the U.N., but he did join five and consultation took up very scarce staff time. other heads of state in expressing a commitment If lack of focus was one problem, mobilizing to developing free health-care systems for staff members to deliver services was another. In pregnant women and young children, a move the capital city, Freetown, with a population of which indicated to ministry staff that the head of two million, fewer than 180 government health state was serious about sustaining the momentum workers had been trained to deliver babies. begun with the health minister’s declaration. Around the country, there was just one doctor for To make the free health-care initiative work, every 33,000 people.1 The World Health Daoh and the president would have to confront Organization recommended a minimum doctor- several weighty challenges. Sierra Leone lacked a to-population ratio of 1:12,000. Six of the national health plan or other statement of health country’s 13 districts offered no emergency priorities. A plan didn’t guarantee success, of obstetric care, preventing women in these districts course, and in many places ambitious visions from receiving potentially life-saving caesarean exceeded capacities. But without a statement of sections or blood transfusions.2 Health staff who concrete objectives, a list of the implementation did appear on the job were often under qualified.3 steps and a timetable, ministers could not manage According to Daoh, 90% of the trained doctors resources effectively. The press of everyday under his supervision left the country during the business impeded government progress on some war.4 of the objectives that mattered most. In turn, Although Sierra Leone lacked trained without a plan, it was difficult for a ministry to doctors, there were other health workers who coordinate at the center of government—for wanted jobs, but the government had little money example, to act on promises a president or prime or administrative ability to support new hires. minister made to the public or promises that Even though they were not on the payroll, some emerged from a national consultation. The of these lower-level practitioners still provided ministry had developed a basic maternal and child care at health centers, where they collected fees health strategy in 2008 under external pressure, directly from patients. but it had gone no further. In addition to lacking capacity to hire staff, A national health plan also would have health centers were often underequipped and in provided an opportunity to coordinate foreign need of basic supplies. “We didn’t have the assistance and the activity of non-governmental facilities. We didn’t have the drug supplies,” Daoh organizations. When the president announced his told an online newspaper in 2011.5 plan in November 2009, a number of projects, Weak internal management within the funded by various donors with differing deadlines, health ministry interfered with the ability to were under way to improve aspects of the health transport supplies to the right locations and sector. Donors often approached the health ensure that nurses, doctors and officials were at ministry individually about funding initiatives. their posts, doing their jobs. “Some people were For example, the World Bank funded a drug- just not showing up to work,” said Erin Chu, an procurement process that was different from the international consultant hired by the U.K.’s # © 2012, Trustees of Princeton University Terms of use and citation format appear at the end of this document and at www.princeton.edu/successfulsocieties

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Department for International Development Clinics needed electricity and other types of (DFID) to work on human resources infrastructure. Therefore, to act on the president’s management issues. Some employees worked promises, health officials would have to work with tenaciously, while others slacked off. Health staff the Ministry of Energy and Power and the pocketed patient fees to supplement their meager Ministry of Works and Infrastructure. The salaries, which, according to Rob Yates, a senior program also required actions within the health adviser with DFID, “were some of the jurisdiction of the Ministry of Foreign Affairs and lowest in all of West Africa.” Muhamed Koroma, International Cooperation, the Ministry of director of corporate strategy and administration Information and Broadcasting, and the Ministry at the Human Resources Management Office, of Internal Affairs, Local Government and Rural who was not related to the president, said that Development. before the launch of free health care, a registered The free health-care initiative presented both nurse in Sierra Leone earned about US$57 a risks and opportunities for the president. Koroma month. He noted that a registered nurse in could score a quick political win at the launch, but Gambia made more than three times as much, continued success of the program would require a US$182 a month. sustained commitment. By the next election in The ministry’s headquarters in Freetown 2012, much could go wrong. At the same time, lacked running water and, despite progress on the initiative was valuable politically because it energy issues, power sometimes went off without had broad impact in a country where ethnic and warning. Susan Mshana, a health adviser with regional loyalties often cast suspicion on projects DFID in Sierra Leone described the ministry as that had narrow benefits for certain groups or “initially a grim place to be.” Another visitor areas. The nationwide program had the potential observed, “There were chickens living in the to affect all people equally and therefore undercut women’s bathroom, and there was total confusion. opposition claims that Koroma delivered services No one knew what they were supposed to be based on political considerations. doing. People would just be sitting at their desks reading newspapers. There was no FRAMING A RESPONSE accountability.” In August 2009, knowing he had to move The vehicles for interaction or collaboration quickly after the health minister’s announcement, within the health ministry were few, and any Daoh reached out for advice and guidance. He effort to improve health care required enlisted the help of Faye Melly, who at the time coordination with other ministries. For example, was an adviser with the Africa Governance the Human Resources Management Office—an Initiative (AGI), and had joined the ministry in extension of the President’s Office—employed April, to lay out the next steps. health ministry staff members. Money for health Working closely with DFID, Daoh and ministry salaries and materials came from the Melly began by creating technical committees to Ministry of Finance. The Accountant General develop a strategy. Each committee addressed maintained the health ministry’s balance sheet. specific issues and included donors, staff from The Sierra Leone Port Authority had control over non-governmental organizations, officials from the main port, through which medicines passed. related ministries, and health ministry managers. Solutions to many public health problems Healthy debates ignited about the grounds for required collaboration with the health ministry. eligibility, vouchers, insurance and other matters.

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In early October, the president told of women pregnant at any point in time, health Parliament that his government had initiated ministry staff estimated nearly 230,000 pregnant innovative responses to the maternal and child women and about one million children stood to health crisis. The following day, Daoh convened benefit from the initiative annually. a one-day workshop at which the technical Money was an issue on everyone’s minds, as committees shared their work and collectively the government of Sierra Leone could not fund agreed on key aspects of the initiative. Daoh then the initiative alone. Gordon Brown, the U.K. assigned a subcommittee to formulate a strategy prime minister at the time, had put improving document based on what was agreed upon. Melly health in Sierra Leone high on his government’s provided advisory support for the subcommittee, foreign-aid agenda. The Government of Sierra which included Daoh and Dr. Samuel Kargbo, Leone’s own research showed cost as the greatest the health ministry’s director of reproductive and barrier to getting care, and Brown wanted his child health. government to support the elimination of user fees Before his health minister’s announcement, as a means to lower maternal and child death President Koroma had expressed interest in rates. Brown also stood to gain politically from developing a national health insurance program in supporting Sierra Leone’s efforts, as the U.K. addition to free health care for pregnant women people supported providing assistance to Sierra and children. But such an insurance program Leone. Since its independence from Britain in would require people—except the very poor who 1961, Sierra Leone had maintained strong were able to obtain waivers—to pay into the relations with its former colonial ruler. That system. Mothers and children were dying because relationship was evident in 2000, when British they did not have money. The health ministry armed forces intervened in Sierra Leone’s civil war submitted its strategy, which did not include an and helped to bring an end to the fighting. insurance component, to the president in late Senior political figures in the U.K. worked October. Upon reading the strategy document closely with DFID to build support for Sierra and hearing from excited donors, Koroma threw Leone. Development partners estimated the total his full support behind the free maternal and child cost of delivering the initiative in 2010 would be health program, which stood to make a greater US$91 million. This figure included the cost of immediate contribution toward the Millennium increases in health workers’ salaries, drugs and Development Goals than an insurance program. medical supplies, logistics, medical infrastructure In a November 2009 speech at a donors’ and support for monitoring and evaluation. conference in London, the president officially Some donors were split over the best way to unveiled the free maternal and child health help. “There was an ideological divergence over program and announced a launch date of 27 April how it would be done,” recalled Andrew Felton, 2010, setting the aggressive six-month timeline in DFID’s former deputy head of office in Sierra order to have the initiative culminate on Sierra Leone. Leone’s Independence Day. Under the program, The World Bank, already a donor to the pregnant women, breastfeeding mothers and health ministry, emerged as a critic of the plan to children under five years old would be able to visit eliminate health-care fees, arguing that such a any government health facility in the country for move would lead to greater dependence on donors any kind of treatment and not pay a single Leone, and less local ownership of the process. The bank the local currency. Based on the average number believed that fees increased the efficiency of

Michael Scharff Innovations for Successful Societies government health services by reducing frivolous GETTING DOWN TO WORK demand for services, and generated additional Koroma’s first step was to name the vice revenue for the health sector. Furthermore, the president, Samuel Sam-Sumana, caretaker of the bank did not believe Sierra Leone was yet capable ministry of health. The move signaled to people of funding its health sector from its own sources. that the president was serious about implementing But the free health care initiative was not just the initiative. “Putting his vice president in about getting rid of informal fees but also about charge of the health ministry underpinned how using the opportunity to reform the broader much importance the president placed on this,” health sector, including improving the quality of said Susan Mshana, a health adviser with DFID services and developing the drug supply chain. In in Sierra Leone. 2010, after prodding from the U.K. government, Next, the president had three objectives: to the World Bank dropped its support for fees in assemble decision makers and figure out Sierra Leone. specifically what was needed to make the program By the time of Koroma’s November work, to solve coordination problems, and to announcement, pledges totaled US$70.9 million develop a system that made more prudent use of and included commitments from U.N. his own time. organizations like the World Health Organization, various NGOs, the Global Fund (a Committees and coordination public-private partnership funding prevention and At the suggestion of Daoh and the vice treatment of AIDS, tuberculosis and malaria), the president, Koroma put a new kind of coordination GAVI Alliance (another public-private system in place, modeled loosely on the delivery partnership focused on children’s health issues), unit model in the U.K., which monitored and and DFID. Although this figure was still short of supported government institutions to carry out the the estimated US$91 million cost of the project, Prime Minister’s priorities. Working with the an estimate based on what an ideal program might president, Daoh created a tiered committee cost, the shortfall did not prevent the government system that explicitly included staff members from from moving forward with its plans. key ministries and donor representatives, bringing Koroma’s announcement jolted people into all the relevant people together in one room on a action but also raised eyebrows. Free health-care regular basis. Technical committees would move systems had been set up in countries around the action forward and address minor issues, while a world, including in Africa, with varying degrees of steering committee would address bigger success. Even the president’s most ardent problems and forward information to Koroma supporters were unsure whether Koroma could when the president’s attention was required. The deliver on his promise. steering committee focused on priority setting and People had good reason to be skeptical. The review. The system would address several of the health ministry had not worked well in the past, challenges the new program posed, including and it was now leaderless. Koroma had fired his internal management, interministerial health minister, who was under indictment on coordination and donor engagement. corruption charges, the day before the Daoh created technical committees for international meeting at which the president infrastructure, finance, drugs and logistics, announced the commitment. Moreover, to make monitoring and evaluation, human resources and the program work, policy coordination across communications. A representative from the ministries would have to improve. health ministry along with a representative from & © 2012, Trustees of Princeton University Terms of use and citation format appear at the end of this document and at www.princeton.edu/successfulsocieties

Michael Scharff Innovations for Successful Societies an international development organization, co- met every other week to monitor the progress of chaired each committee. Staff members from the technical committees. Finally, the president other ministries sat on the committees where the held monthly meetings for progress updates from work of the group was relevant to their ministry. the steering committee. Non-governmental organizations that had a role Temporarily, Melly acted as Daoh’s aide. to play also sat on the committees. Before the steering committee meetings, she Monitoring was important to ensure that briefed Daoh on the top issues and priorities for things got done. The Bumbuna hydroelectric the meeting. She provided Daoh with an project, which had just come on line, had annotated agenda, which showed the status of introduced the use of trackers to keep tabs on each of the issues up for discussion. “The steering progress of specific action items. Trackers, simple group meetings were a very good format,” recalled spreadsheets created with off-the-shelf software, Daoh. “Information was shared and we discussed listed key priorities, the status of work on the how we would overcome the challenges.” priorities, and the ministries and individuals The co-chairs of each technical committee responsible for delivery. Trackers had helped the were required to present their trackers. Dr. Bumbuna team organize and monitor key aspects Augustine Sandi, a medical doctor, and the co- of the project, and Koroma encouraged their use chair of the human resources technical committee, for the free health care initiative. said that when it came time to presenting his In November 2009, the health ministry tracker to the steering committee: “We all sat gathered all of the new technical committees at a together, we planned together, we discussed local hotel. In the dining room with sweeping together and we took a common position views of the city and distant Atlantic Ocean, together. It was quite a good setup.” Melly Daoh explained the reason why the committees recalled that at the steering committee meetings, were created and what he and the president “You had a pretty impressive group of people expected of them. He instructed committee looking at the trackers and asking, ‘Why the hell representatives to identify and list the top 10-12 isn’t this being done?’” things they needed to do. “Each one of the The steering committee expected the working groups faced a massive number of technical committee co-chairs to be clear on how challenges,” said DFID’s Mshana. “Prioritization the steering committee could best support their was very important.” The priorities decided at activities. “It was such a tight governance system this meeting became the basis for the priorities that no one had anywhere to hide,” recalled Melly. listed on each technical committee’s tracker. Meetings also promoted cooperation. “Getting The committee structure also served as a way something done wasn’t on any one person. It was to accelerate specific projects and align completion a partnership,” she said. dates under the banner of the free health-care As time passed, steering committee meetings initiative. To do this, each committee surveyed became crowded affairs, reflecting the number of the work already under way in their sectors and people who wanted to stay abreast of the latest formulated specific priorities for their trackers. planning and decisions. The health ministry did Each technical committee met weekly and not limit participation, and representatives from reported to the steering committee, which U.N. agencies and non-governmental Koroma asked Daoh to chair, with the vice organizations, consultants, ministry officials and president also present. The steering committee presidential advisers all packed shoulder-to-

Michael Scharff Innovations for Successful Societies shoulder in the health ministry’s cramped out to the committee co-chairs for clarification. conference room. “It was initially frustrating Daoh had an open line of communication when the number of participants increased with Gilpin. On multiple occasions, Daoh asked because people had not read previous meetings’ for private meetings with the president. “I notes and asked many questions that took us back requested meetings with the president to show to square one,” said Melly. “But the positive side him that I was on top of my stuff,” Daoh said. was that more people were engaged, knew about The meetings strengthened the trust between the the government’s plans, and, importantly, were two leaders. proposing solutions for addressing implementation challenges.” Mobilization and monitoring The meetings could last as long as five hours. At each technical committee meeting, After the meeting, advisers from AGI would attendees decided which of three colors—green, compile a one-page document on actions agreed yellow or red—to assign to each action item on upon at the previous steering committee meeting the trackers. Committee participants used red to and the status of projects. The document also signal that action items required the steering listed what the steering committee participants committee’s review, often because work was saw as potential risks and issues that could behind schedule and needing help from senior negatively impact on launch plans, and included leadership. Yellow signaled an optional review by space for staff to describe what mitigating actions the steering committee, and green marked action they were taking to ward off potential trouble. items that were on schedule and required no help. This document formed the basis of discussion at The tracking system required explanation in the the president’s monthly meeting that served as the early days because the colors were initially final link in the committee structure. meaningless. Sierra Leone had only one three- The presidential meetings brought together color traffic light, and it did not work. senior ministry officials and heads of donor groups Initially, almost all technical committee and foreign missions. Mshana of DFID attended actions were reactive, dealing with problems as the meetings and recalled they were accompanied they arose. However, the drugs committee by “a lot of head banging by both the president enjoyed some success in thinking strategically and vice president.” Typically, the issues brought about quantities of drugs and medical supplies. to this meeting required the direct involvement of Its partner was UNICEF, which had experience the president and his team. in drug procurement, storage and distribution. Although the committees created formal UNICEF’s staff members helped Sierra Leone channels of communication, behind-the-scenes partners review the experiences of other countries discussions between donors and implementing that had launched free health-care systems. They partners, and with the president and his inner crunched numbers, reported the figures to the circle, helped decision makers respond before committee, and in January placed an initial order. issues ballooned. For instance, Brian Gilpin, the “They were very intelligent estimates,” Mshana president’s personal assistant, briefed Koroma said. before the monthly presidential meetings. He Although each committee had a list of kept an ear to the ground and could alert the responsibilities, committee personnel had not president if he thought a committee needed extra explicitly laid out how each would be prodding or supervision. Gilpin could also reach accomplished. “Initially, we looked at the anthills

Michael Scharff Innovations for Successful Societies but not the ants,” said Mahimbo Mdoe of caliber of the operation when she arrived. “The UNICEF. Mdoe cited the example of the main coordination and cooperation was amazing. drug storage warehouse in the capital. “The drug People were really enthusiastic about making it and logistic committee’s tracker would have said, work,” she said. “There was a lot of energy.” ‘central warehouse to store drugs and medical Booz representatives proposed a way to clean up supplies,’” explained Mdoe. “That was our anthill. the payroll and won the agreement of the But beyond that, no instructions were given as to ministries and the technical committee. specifically how to make that happen. There were As a next step, health ministry officials huge challenges. The place needed to be assembled the top health officials from each refurbished, hooked to the central power grid, and district at a Freetown hotel and asked the district inventory systems had to be set up. Those were staff for support in cleaning the payroll. In a the ants.” country that lacked reliable communications, the meeting offered the opportunity to inform the Staffing the initiative district personnel of pending changes to the “Our first reaction at the human resource health system, answer questions and allay office to the president’s November announcement concerns or misconceptions. was, ‘Do we have the manpower?’” said Muhamed The Human Resources Office drew on three Koroma. Based on the number of known health different sets of information to weed out people facilities and international guidelines on the who were not working. First, the ministry had its proper doctor-to-population ratio, the health own official payroll. Second, ministry staff got ministry had calculated that about 3,000 new hold of a headcount the health ministry had done health workers were needed to address widespread in late 2009. Ministry officials cross-checked the staff shortages. two sets of information. The officials took a Before they committed money to pay for new conservative approach and, rather than delete hiring, DFID officials said they wanted to ensure names, flagged those that looked suspicious for that employees listed by the ministry were actually the district staff to examine. The updated lists, by on the job. It was an open secret that retired district, appeared on spreadsheets that were sent personnel, the relatives of staff members who had to the district staff at the Freetown meeting. To died, and staff who were working or studying bolster the department’s authority, Muhamed abroad, often still collected pay from the ministry. Koroma’s team would write “The President’s Free Coordinating the removal of former and Health Care Initiative” on the top of the delinquent staff from the payroll and the hiring of spreadsheets, and when giving instructions did not new staff fell to Human Resources Office, which hesitate to reference the president. “During the worked closely with the other organizations that payroll cleaning process, the ministry staff warned had a stake in the process including the health and the district staff to report accurate figures because finance ministries, the accountant general’s office, ‘Pa’ would be checking,” said Chu, citing how and donors. The human resources technical some referred to Dr. Daoh and the president. committee provided oversight and ensured that The district staff worked with staff at the efforts moved ahead. health centers to gather the data, and sent their In February, DFID hired the international updated lists back to the Human Resources consulting firm Booz & Company to assist the Office. Did opportunities exist for district staff to ministries. Erin Chu, the Booz team leader for fudge the results? “Of course,” said Chu, “but in Sierra Leone, said she was impressed with the this rapid type of situation you just needed to trust )* © 2012, Trustees of Princeton University Terms of use and citation format appear at the end of this document and at www.princeton.edu/successfulsocieties

Michael Scharff Innovations for Successful Societies people to do their jobs.” Chu said initial estimates payroll, the more people that would be sharing were that about 850 people who were not working from the salary pot, and the government had yet were still on the payroll. to contribute any money.” Donor commitments Next, the ministry referenced the district lists from the previous November covered only the and compiled a single list and flagged 3,000 hires that had been planned originally. The questionable individuals. The nearly complete list donors, said Koroma, “were not upset. They then went to the health ministry, where Daoh had inquired as to why I had hired so many people, the ultimate say as to which individuals would and I gave my explanation. They were pleased have their pay frozen. In the case of freezing that the entire country was now being covered people’s pay, Daoh consulted with the accountant with health staff.” DFID offered additional funds general’s office and the Ministry of Finance to to cover the extra staff. ensure that payments stopped. People could The president closely monitored appeal Daoh’s decision to remove them by visiting developments in cleaning the payroll and hiring. the Ministry of Health in person, but few did. Because the success of free health care hinged so Expanding the number of health workers was much on having enough health staff to care for the next step after non-workers were eliminated. patients, he decided to hold monthly meetings at The director general of the Human Resources his office to track progress. These meetings were Office assigned Muhamed Koroma to lead the separate from the monthly presidential meetings recruitment drive. Using radio and newspaper that were a part of the committee structure and ads, the ministry announced its plans to hire and afforded the president opportunity to become said it would send representatives to each district more involved in critical issues. to interview applicants. People who wanted to compete for the jobs had to prove that they held Managing expectations proper diplomas and complete a formal interview. The president knew that scoring a political If they passed both steps, they were hired on the victory meant winning citizen support. Managing spot. There was no time to double-check the the public’s expectations required an effective validity of the diplomas. “Because of the nature of communications strategy. The communications the situation we had to break a lot of regulations,” technical committee coordinated the effort to conceded Koroma, noting that he struggled to convey two important messages: first, that the ensure that all hires were qualified to do the jobs government intended to launch a free health-care they were hired to do. initiative, and second, that the initiative was But there was more. “I was instructed to permanent and would not fold after a few weeks recruit only 3,000 new staff, but I returned to or months. The second message sought to Freetown having hired 5,800 workers,” said prevent a crush of visitors to health centers Koroma. He said the health ministry’s data immediately after the launch. undercounted the number of actual health “People wanted to hear President Koroma’s facilities and therefore the recruitment figure was voice on the radio,” Melly said. “He was the only too low. Koroma’s boss had given him permission one who could really get the message out there to increase the number of recruits. But Koroma’s and convince people of the legitimacy of the actions angered other senior ministry officials. initiative. So we knew we had to have his “At that time, the Human Resources involvement.” The communications committee Management Office had an incentive not to hire worked with the president’s office to put him on more people,” Koroma explained. “The bigger the the radio and had him sit for multiple print-media )) © 2012, Trustees of Princeton University Terms of use and citation format appear at the end of this document and at www.princeton.edu/successfulsocieties

Michael Scharff Innovations for Successful Societies interviews. The committee also helped plan a pay were grounded in part on initial donor tour for the chief nursing officer to visit all of the commitments.) districts to spread word about the launch. At the time of the meeting, the finance To manage the health ministry’s day-to-day ministry had already begun exploring ways to media efforts, Daoh turned to his trusted make broader reforms to public sector pay, which colleague, Dr. Samuel Kargbo. Gifted with a would entail restructuring the civil service pay commanding voice, Kargbo was a powerful public scales and moving to a 17-grade system. The speaker who relished the chance to go toe-to-toe minister of finance asked the health ministry to with the media. He had a medical degree, a align its proposal with the broader 17-grade compelling background story—during the war he system. Signaling the prominence of the free had ventured behind rebel lines to provide life- health-care initiative on the country’s saving care—and he knew how to talk his way development agenda, officials also agreed at the through tough topics, proving efficient at meeting that, although public sector reforms explaining the initiative and staying on message. would be phased in throughout 2010, they would start with the health ministry. OVERCOMING OBSTACLES About two weeks after the meeting, the The president relied on informal channels health ministry’s plans were upended when health and quick thinking to navigate the initiative’s workers nationwide went on strike. Somehow, biggest stumbling blocks. the health workers had gotten their hands on the salary proposal that Daoh and his colleagues had Health workers’ strike presented to the finance minister. The workers, At the end of February 2010, health officials, realizing that the government was not prepared to including Daoh and Magnus Gborie, the health pay them what they wanted and concerned that ministry’s director of planning and information, whatever increases they received could take the met with the vice president and Samura Kamara, government months to pay, went on strike. minister of finance and economic development. The strike had an immediate impact on the They presented Kamara with a detailed proposal country as well as the ministry’s plans. Health to increase health workers’ salaries that adhered to centers were left without staff, which may have Sierra Leone’s 14-grade civil service pay structure. contributed to deaths.6 Some of the civil servants The proposal reflected salary increases based on at the ministry were doctors, and they put down three different scenarios: a 20% increase to each their work and rushed to attend to patients, which pay grade based on the salaries for 2009, slowed efforts to plan for the launch. percentage increases based on levels of President Koroma grasped the urgency of the qualification, and what health workers had situation and gathered his team in an emergency requested in informal conversations with the session. Events moved too quickly for the lengthy health ministry. The health officials told the negotiations required to secure new aid finance minister they were willing to increase commitments. When the president’s aides salaries more than the first two scenarios but at a proposed relatively modest increases, the strikers number less than the health workers had refused them. Koroma sensed he needed to requested, which in some cases was five times confront the striking workers directly. The what the workers were already earning. (The president’s staff gathered workers in a sweltering salaries the health ministry said it was willing to auditorium in central Freetown, where Koroma

Michael Scharff Innovations for Successful Societies explained the reasons behind the changes and which brought the salaries more in line with stressed how much he valued their contributions. neighboring countries. The government began Tensions rose when a handful of workers stood up paying the new salaries into health workers’ bank and turned their backs to the president, a massive accounts the day before the launch of free health sign of disrespect. care. Unable to make headway, the president, The increased salaries combined with the growing increasingly frustrated, told the striking new hires meant the wage bill jumped from US$6 workers that he was willing to sit down with their million to US$19 million. Because it took time representatives, but only if the meetings were for DFID to secure the additional financing, the secret. Koroma was nervous that if word got out government paid the April salaries at the new that he was personally negotiating with the adjusted wages, plus back pay for March. Starting striking workers, teachers and other public in May, DFID covered virtually every penny of employees might also strike. Days later, he met the shortfall. It helped that Sierra Leone’s with the heads of the doctors and midwives minister of finance, a former executive at the associations and some younger doctors at his World Bank, was trusted by the donor home. Koroma told the group that his hands community. were tied. The government did not have the money. He asked them to accept the offer on the Behind schedule table, but the group refused. The protracted negotiations with the striking Koroma knew he had to make it work health workers had diverted President Koroma’s somehow, despite warnings from the International attention away from other urgent matters, one of Monetary Fund that increasing health workers’ which was probing the reasons behind the slow salaries might cause other public sector workers to pace of renovations and construction at health ask for salary bumps as well. He discussed the facilities, which he had earlier learned were problem with his minister of finance and proposed behind schedule. Koroma wanted to see first- even greater increases. The minister told the hand what was going on, and he set out on a president that the government could probably helicopter tour of the country’s health facilities. cover an initial one-month period with the higher Returning to Freetown after the tour, wages, but no more. Koroma held a meeting with consultants and At the same time, Yates, an expert on health contractors responsible for constructing and financing, quickly put together a short document refurbishing health facilities, including medical that he circulated among senior leaders at DFID, stores. Also present were the vice president, the justifying why bold pay increases were appropriate deputy health minister, senior officials from the given the current salary levels. DFID told health ministry, and donors. The president was Koroma they would help cover the increased concerned that things were not getting done and salary costs for an initial period. With the launch admonished the contractors for the slow pace of less than a month away, and the strike in its progress. “I have done an on-the-spot inspection second week, these assurances were all Koroma of these facilities,” Koroma told the group, needed. He called the representatives back to his according to an official record of the meeting. home and agreed with them on the revised “There is work in progress, and there is work to be figures. The president raised nurses’ salaries from completed. Commitments were made, promises US$50 a month to US$250, and increased were made.” The president then demanded an doctors’ pay from US$250 a month to US$1,000, update on progress in each of the four )" © 2012, Trustees of Princeton University Terms of use and citation format appear at the end of this document and at www.princeton.edu/successfulsocieties

Michael Scharff Innovations for Successful Societies geographical regions of the country. Officials the fees be waived. After the meeting, the provided approximations on when facilities would president’s office called the port operators and reach completion. The president threatened to pressured them to release the containers. Days blacklist contractors that did not deliver. “From later, a long convoy of trucks snaked its way from that day until the day of the launch, we had daily the port to the central holding site in the capital. meetings where we discussed progress on The military lent four trucks and multiple infrastructure projects,” said Daoh. Most of the personnel to ensure the safe delivery of the drugs major renovations and construction were and supplies. “The movement of the 30 or so completed just days before the launch. containers caused so much traffic it nearly shut down Freetown,” Mshana said. Drugs stuck at ports A week before the launch, the central ASSESSING RESULTS medical store had received only 20 of the 50 The sun had not yet risen on the morning of containers of drugs and medical supplies that had April 27, and already people queued in long lines been ordered. The remaining 30 containers were outside of health centers around Sierra Leone. locked behind the barbed-wire fence at the port. President Koroma’s motorcade brought him to Some of the drugs were at risk of spoiling. The Freetown’s Princess Christian Maternity Hospital, president called in representatives from the where he made his way to the podium. People privately-owned port company and customs waiting in line reached out to shake his hand. officials and instructed them to work with Speaking in the local language, Krio, he told those UNICEF to clear the containers. gathered before him that from that day on, There were two dominant issues. First, each pregnant women, nursing mothers and children container had a bill of landing and tax exception under five would no longer have to pay to get care. form that required the signature of multiple Cheers erupted. authorities including the ministries of health, After the launch, the number of pregnant foreign affairs and finance, and the national women and children visiting health centers revenue authority. To get the signatures, workers dramatically increased. The average number of had to pass the paperwork between the different outpatient visits at health centers swelled from ministries and agencies. This process could take 367 visits before the launch to 1,375 one month as long as two months, after which the port had to after the launch. The mortality rate for May 2010 conduct its own screening procedures. Along the was 10%, which was an improvement over April’s way, the paperwork sometimes sat unnoticed in 13% and far better than the 18% rate for May signatories’ mailboxes. Other times it was 2009.7 misplaced. Second, the longer it took for ministry The initiative saw a change in the staff to sign the forms, the longer the containers relationship between donors and the government. sat in the ports, which meant the more fees the Before the launch, donors often approached the port operators charged. Koroma appealed to the health ministry individually with their own port operators to waive the interest fees and set a agendas. The free health-care initiative 10-day limit for circulating the paperwork. coordinated donor efforts around a project that At the next presidential meeting about a the government wanted and led. The president’s month later, most of the containers still sat at the clear vision and strong political will guided the port, and, according to Mshana, “the president government’s efforts to improve the country’s was furious.” The president again insisted that health sector. )# © 2012, Trustees of Princeton University Terms of use and citation format appear at the end of this document and at www.princeton.edu/successfulsocieties

Michael Scharff Innovations for Successful Societies

The overall outcome, however, hinged on the Koroma had only faint success in managing efforts of a core group of enthusiastic leaders who his schedule. Unexpected challenges during the came together, agreed on a strategy to overcome planning for the launch required the president to the deficit in government capacity, and then react quickly. Brian Gilpin, the president’s followed through. “Free health care united all of personal assistant, struggled throughout the pre- the partners around one objective,” said Mshana, launch phase to strike a balance between involving and each played a unique role. For example, the president in matters and trying to intervene on Daoh, by virtue of his position as the chief the president’s behalf. medical officer and head of the steering Although the committee design gave some committee, was the linchpin and was supported by structure to the flow of information, people often senior leaders at the other ministries. And AGI sought the president’s authority to resolve even advisers helped reformers develop tools that minor issues. Bombarded with requests, the enabled them to prioritize. president found it hard to determine where his The committee structure proved critical. intervention was really needed. As a result, many Prioritizing tasks made achieving results seem of Koroma’s actions were more reactive than more manageable. “Before the committees, strategic. “His time was ad hoc and not always ministry staff just saw this huge monstrous planned. He had to constantly react to issues that problem,” explained Mshana. “The committees arose,” Melly said. helped to break down the issues into bite-size Mdoe said the president sought to insert pieces that could be tackled. This helped to boost himself into the planning process only when it morale.” With such a tight time frame, was most needed. Too much involvement by the prioritizing helped keep everyone focused on the president could have consequences. The most important tasks. “We had to do in six UNICEF boss cited an example: “When he [the months’ time what normal policy processes would president] called the port operators and demanded take five years to do,” said Mdoe of UNICEF. the containers be released, he risked alienating “Six months gave everything a sense of urgency.” ministry officials whose job it was to do precisely The committee structure also led to greater this.” cooperation. The co-chair design stopped the Although by mid-2010 the president was not cycle of donors going to the ministry, dictating as personally involved as before the launch, free terms and putting all responsibility on the health care remained at the top of his agenda, and ministry. Rather, the co-chair structure his administration still focused a substantial established mutual responsibility to see that amount of time and energy to ensuring its success. priorities were implemented. “The co-chair The president’s Strategy and Policy Unit, structure promoted shared accountability of overhauled after the launch to improve on the work,” Melly said. delivery of the president’s priorities, labeled free Importantly, the people who co-chaired the health care a “flagship priority,” meaning that it technical committees weren’t just political received more attention than most other agenda personalities who owed their loyalty to the items. president. Rather, they were technical and One by one, the committees stopped meeting operational experts in the areas they covered, after the launch, but challenges remained. which helped them win the respect of Despite the health ministry’s hiring 5,800 new subordinates. workers, there were still only about 80 doctors on

Michael Scharff Innovations for Successful Societies the payroll at the time of the program’s launch, not miss the meetings,” Mdoe said. and health facilities were still in need of highly Dr. Kisito Daoh, the chief medical officer, trained staff. Furthermore, the government still said that getting things done in a place like Sierra had to improve the quality of care and put in place Leone required a significant investment in time tougher monitoring and enforcement mechanisms and energy, something Koroma recognized early to ensure health staff showed up for work and did on. “You have to realize this is a long-term not collect fees. In September 2011, a report by investment,” Daoh said. “Otherwise, you will get Amnesty International said that the quality of easily disappointed, lose interest, and people healthcare was “frequently substandard, and many around you will fail.” women continue to pay for essential drugs despite “We also have a very strong, committed team the free care policy.”8 in the ministry,” Daoh told an online newspaper In late 2011, questions continued to linger in 2011.9 “Free health care actually put everyone over the sustainability of the program. The together in one boat with a very strong Minister of Finance, Kamara, and his colleagues, commitment, a very strong drive to succeed. And with support from DFID and the World Bank, that keeps you going as chief medical officer.” were studying how tax revenues from the Daoh pointed to the committee structure as a extraction of the country’s rich mineral and oil key element in addressing the government’s deposits could be used to help fund the initiative capacity problem. “I would advise other countries over the longer term. Yet for the foreseeable trying something similar and faced with future, the government likely would rely on the comparable obstacles in government to set up a donors to foot most of the bill. committee structure so that there are regular meetings and people are aware of progress,” Daoh REFLECTIONS said. He cautioned, however, that even with a The success of the free health-care initiative rigorous reporting and information sharing hinged on getting the partners and structures in system, simply holding meetings did not give place to prioritize and coordinate efforts. But leaders all of the facts they needed to make having a determined executive with a strong vision decisions. Leaders had to experience the projects who exercised a leadership role throughout proved first-hand, said Daoh. He cited Koroma’s just as important in Sierra Leone. helicopter tour: “People, including the president, “He was the authorizing sponsor,” said Faye were not fully aware of the complexities of Melly of the Africa Governance Initiative, providing health care. But after his visits to the referring to Koroma. “The Ministry of Health health centers, he realized it was much more did eventually show true leadership, but he was complex than what had been written in the certainly there during times of troubleshooting reports.” and always acted as the figurehead.” The complexities were not lost on those Koroma’s hands-on style of leadership involved. “This was a hard win for the president,” impressed Mahimbo Mdoe of UNICEF. “When said Felton, DFID’s former deputy head of office he would call these meetings with all of the key in Sierra Leone. “Reforming institutions is so actors, he would actually stick to his schedule and much harder than building a new dam.”

Michael Scharff Innovations for Successful Societies

1 CARE International, Maternal Mortality: A Solvable Problem (2010), 2 Amnesty International, Out of Reach: The Cost of Maternal Health In Sierra Leone (2009), http://www.amnesty.org/en/library/asset/AFR51/005/2009/en/9ed4ed6f-557f-4256-989f- 485733f9addf/afr510052009eng.pdf (9 January 2012). 3 Government of Sierra Leone, Free Healthcare Services for Pregnant and Lactating Women and Young Children in Sierra Leone, (2009): 9. 4 “Reducing Fees to Lower Child, Maternal Mortality Rates,” AllAfrica, June 23, 2011 (http://allafrica.com/stories/201106240047.html). 5 AllAfrica, June 23, 2011. 6 “Sierra Leone Doctors and Nurses Get Massive Pay Rise,” BBC News, March 28, 2010 (http://news.bbc.co.uk/2/hi/8591682.stm). 7 Sierra Leone Ministry of Health and Sanitation, Free Health Care Initiative, (2010): 6. 8 Amnesty International, At a Crossroads: Sierra Leone’s Free Health Care Policy (2011), http://www.amnesty.org/en/library/asset/AFR51/001/2011/en/4de27bf1-aebb-4944-8005- 1458b4c44edb/afr510012011en.pdf (9 January 2012). 9 “Reducing Fees to Lower Child, Maternal Mortality Rates,” AllAfrica, June 23, 2011 (http://allafrica.com/stories/201106240047.html).

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