Some people scoffed at Sierra Leone’s plan to make health care free for all children under five, pregnant women and mothers who were breast-feeding. How could a country at the bottom of the world’s health indicators suddenly open the doors to all government health facilities and say there is no charge for service?

Now, six months after the start of free health care, Sierra Leone has proven it could do it.

“There’s so much difference now,” said H. E. President Ernest Bai Koroma in an interview. “Our hospitals and clinics are much better equipped than before, the workers are happier – you can see it in their faces. And we have so many more children and mothers coming in, and they are coming in without fear of how they would pay for this. That is different.”

Most of the early indicators are impressive. Overall, the numbers of children and mothers seeking medical help have doubled since the start of free health care in late April, including the number of mothers giving birth in government health facilities. The use of anti-malarial drugs for children under the age of 5 increased by even more: a 372 percent increase in May compared to a year before.

And in a small sign that the system is gradually improving, if far from optimal, 70 percent of the country’s hospitals are now sending complete statistical reports to the Ministry of Health, compared to 30 percent in 2007. It is a figure that perhaps only health policy wonks may fully appreciate, but it is one indicator of a system now functioning better.

Koroma, senior officials at Ministry of Health and Sanitation, donors, and non-governmental organizations also note that things aren’t perfect, and the country’s free health initiative faces a host of challenges. Those challenges include lessening the burden on health care workers from the huge increase in new patients; training and hiring more health workers; ensuring quality service for patients; and streamlining the drug distribution system to make sure all hospitals to health posts have enough medication.

In addition, perhaps because so many more people have come seeking care and filled up some waiting rooms, others may not be receiving basic services. In the second quarter of 2010, April to June, antenatal services for pregnant women and immunization for children both declined slightly, compared to the first quarter of the year. The bottom line, though: Observers now see a huge improvement in health care because of the free health care initiative.

“Six months in, we on average are seeing a doubling of the number of children and mothers seeking care – that’s phenomenal,” said Susan Mshana, DFID’s Human Development Team Leader & Health Adviser in Sierra Leone. “We’re still at that level, which is a bit unusual compared to other countries that have offered free health care. In other places, the use of services drops off after a couple of months. It is a very clear indication that there had been major barriers accessing health care.”

Mshana particularly noted the increase of children receiving malaria treatment. “That’s a three-fold increase,” she said. “It’s quite stunning, staggering even.”

Why has it worked so well in Sierra Leone? Analysts point to many factors, including well-organized efforts led by both the Ministry of Health and Sanitation and by donors and partners, including DFID, the World Bank, UNICEF, Tony Blair’s Africa Governance Initiative, Irish Aid, Save the Children, and many others. But perhaps the biggest factor has been the involvement of President Koroma, many said. Koroma announced the launch of free health care in a meeting with donors in London in November 2009, and then pushed the planning throughout the process, including taking a three-day tour of health facilities around the country prior to the launch.

Koroma said in the interview that the free health care launch became his most important priority. Why? Just look at the health indicators, he said.

“I inherited a health sector that was in shambles, a health sector that was giving us terrible health indicators, where one out of eight women was dying in childbirth, one out of every 10 children was dying before the age of five. Our hospitals are not properly equipped, and we had been lagging for so many years in the human development health indicators.”

He said he had no choice but to build a health care system.

“Something had to be done about it,” he said. “If we have to save this nation, if we have to build a healthy nation, if we want children to have a future, and families to be happy, there had to be a turnaround.”

Is he satisfied now six months after the launch of free health care? He offered a qualified yes.

“I am happy because we have experienced a substantial increase in the number of women and children who are now coming to clinics,” he said. “Clearly, they could not access this before. That is one sort of comfort. The other is health centers are now better equipped than before and there is an improvement in the service delivery. And the donor communities are coming along with us, giving us great support.

“But,” he added, “we obviously still have problems. We still have the problem of inadequate facilities and limited numbers of personnel. One question ahead for us will be what happens when the donors leave and how do we sustain the progress. I feel, though, we will find a way.”

The Ministerial Leadership Initiative for Global Health works with Health Ministry leaders in five nations, including Sierra Leone, in country-led efforts to improve donor coordination, health financing for equity and reproductive health.