The paramedic’s eyes were bloodshot, his features drawn. Pregnant women jammed into the darkened concrete bunker, just as they had yesterday and would tomorrow. The increase in patients had been fivefold, or tenfold. The exhausted paramedic had lost count in a blur of uninterrupted examinations and deliveries.
The word was out: it was no longer necessary to give birth at home and risk losing a baby or dying in childbirth. Hadiatou Kamara, 18, waited in the crowd. She had already lost a baby boy and girl. “They both died,” she said quietly.
Now, for her third pregnancy, she was at this rural health clinic outside Freetown, the capital. The Sierra Leone government has eliminated fees for pregnant women and children, and Ms. Kamara, like thousands of women in a country where surgery has been performed by the light of cellphones and flashlights, could afford trained medical staff to oversee her pregnancy for the first time.
At the Waterloo Community Health Center here, the women were spilling out the door, as they have consistently since the fees were lifted last year.
Sierra Leone is at the vanguard of a revolution — heavily subsidized for now by international donors — that appears to be substantially lessening health dangers here in one of the riskiest countries in the world for pregnant women and small children.
Country after country in sub-Saharan Africa has waived medical fees in recent years, particularly for women and children, and while experts acknowledge that many more people are getting care, they caution that it is still too early to declare that the efforts have measurably improved health on the continent.
In Sierra Leone, though, it seems clear that lives are being saved, providing an early and concrete lesson about the impact of making health care free for the very poor and vulnerable.
By waiving the requirement for payments — which sometimes amount to hundreds of dollars and clearly represent the main barrier to using health facilities — the government here appears to have sharply cut into mortality rates for pregnant women and deaths from malaria for small children.
The results in Sierra Leone have been “nothing short of spectacular,” said Robert Yates, a senior health economist in Britain’s Department for International Development, which is paying for almost 40 percent of the $35 million program, with most of the rest coming from donors like the World Bank. Since waiving the fees, Sierra Leone has seen a 214 percent increase in the number of children under 5 getting care at health facilities, a 61 percent decrease in mortality rates in difficult pregnancy cases at health clinics, and an 85 percent drop in the malaria fatality rate for children treated in hospitals, according to figures Mr. Yates supplied.
“We have signs that there are positive results,” said Vijay Pillai, the World Bank country manager in Sierra Leone.
In recent years, Zambia, Burundi, Niger, Liberia, Kenya, Senegal, Lesotho, Sudan and Ghana have gone to some form of free care, particularly for pregnant women and young children, Mr. Yates noted two years ago in the health journal The Lancet. Rwanda has been offering nominal rates for health insurance for over a decade, and after fees were dropped in Burundi in 2006, average monthly births in health facilities rose by 61 percent and Caesarean sections went up by 80 percent, he found.
“It’s absolutely common sense that if we increase the consumption of the services,” improvements in health follow, he said. “It’s blindingly obvious. We know these medicines work.”
Still, the hurdles loom large. Here in Sierra Leone, the health minister, Zainab Bangura, says her country needs 54 gynecologists but has only 4. Likewise, she says, there are only two pediatricians in a nation of over five million people. “We lost 10 years” to civil war, Ms. Bangura said of the impetus behind increasing access to health care. “We needed to embark on a drastic measure.”
But donors will not finance the program forever, and the hope is that revenues from the mining of diamonds and minerals, shaky for now, will replace them. Beyond that, Unicef recently discovered that drugs equivalent in value to 14 percent of what it had donated were missing. The agency has demanded an investigation.
Given how recent, untested and strained some of the efforts to provide free health care are, some researchers are reluctant to make an automatic correlation between better access and better health. The outcomes are “not very straightforward,” said Sophie Witter, a senior research fellow at the University of Aberdeen, in Scotland, who has studied the elimination of fees in Africa.
Lucy Gilson, a professor of Health Policy and Systems at the University of Cape Town, agreed: “I wouldn’t be prepared to say specifically it’s had x or y in terms of health outcomes.”
But Sierra Leone, still scarred by a brutal decade-long civil war — men whose limbs were chopped off by rebels play soccer, using their prosthetic ones on a beach in the capital — hovered at or near the bottom in maternal and infant mortality tables.
It had nowhere to go but up, which may be why there appears to have been an immediate benefit from the lifting of fees. The nihilistic rebels of the Revolutionary United Front deliberately took aim at health care facilities, as symbols of government authority.
“This was about stopping it from being the worst place in the world,” said Dominic O’Neill, a British official who until recently headed the Department for International Development’s office in Sierra Leone. “It’s an emergency response to what was a humanitarian crisis. It was about stopping people dying.”
Although the worn-out community health officer here in Waterloo, Jimmy Jajua, complained that demand was so high he had “no time to go off duty,” he noted that maternal deaths had dropped “drastically” now that his rudimentary clinic, still without electricity, charged no fees.
Women at the clinics said they felt safer, having traded risky home births for at least some medical care.
On a recent morning at Freetown’s main maternity hospital, about 80 women crowded into the prenatal examination waiting room, filling benches that doctors said had been sparsely populated in the past. Most of the women raised their hands when a nurse asked how many had been able to come to the hospital simply because the fees had been eliminated. The mood was upbeat. In unison they sang, “We are the pregnant women, and we are saying good morning.”
Up in the spartan wards of the 1920s hospital, with its whitewashed walls and rolling metal-frame cots, there was little nostalgia for home births. “They don’t take proper care of you at home,” said Fatamatou Touray, 39, who had previously lost three children.
And doctors said that while they were swamped, the more patients they saw, the bigger the difference they made.
“I’m the only surgical hand here, seven days a week, and nights as well,” said Dr. Ibrahim Bundu, chief medical officer at the hospital in Makeni, northeast of Freetown. “It’s only patriotism that keeps me going.”
As the former British Prime Minister Tony Blair, whose foundation, the Africa Governance Initiative, has helped set up the program, said, “For many in Sierra Leone, this is literally the first time they’ve had something like this.”