This brief highlights how Sierra Leone can improve the sustainability of the free health care initiative (FHCI) financing, lower household out-of-pocket (OOP) payments on health care, and decrease its dependence on donors. A secondary analysis provides insights into how Sierra Leone could work towards achieving its longer-term health goal of Universal Health Coverage (UHC).

If Sierra Leone’s FHCI and UHC policies continue as they are, both areas will be increasingly underfunded within ten years. Neither the economy, nor the tax base, is projected to be strong enough to create the fiscal space to invest as needed in health if current policies are sustained. With a reprioritised focus on the FHCI financing policy, the resource gap can be closed.

The most effective domestic financing mechanism is government spending, whether purely budgetary or health insurance allocations. The continuation of external donor support is essential to continue to deliver FHCI and UHC services in an effective manner throughout the country. The government needs to improve Public Financial Management (PFM) in the health sector in order to increase the confidence of donors.

For other reports in this series on Sierra Leone’s Free Health Care Initiative, see:

• Sierra Leone’s free health care initiative: financing implications
• The free health care initiative (FHCI) in Sierra Leone: real gains for mothers and young children
• Monitoring and evaluation in Sierra Leone’s health sector