At the biggest maternity hospital in Sierra Leone, doctors keep running out of medicine. The number of hospital births is six times higher than in 2010, and the drug supply just can't keep pace with the astounding increase.
The drug shortage is a worrisome side effect of one of the world's most extraordinary health stories. Until recently, Sierra Leone was the most dangerous place on the planet to become a mother. Most women were obliged to give birth at home, aided only by traditional attendants with little training.
The maternal death rate in this West African nation was the highest in the world: one of every eight pregnant women died in childbirth, and one of every five children died before the age of 5.
Then, in 2010, the government took a dramatic step: It eliminated all health-care fees for pregnant women and mothers of young children. The reform has been hugely successful and the death rate has dropped sharply. But is it sustainable? The country's hospitals are overwhelmed with new patients, the drug supply can't keep up, the medical staff are overloaded, and it's unclear if the $36-million program would survive without foreign donations.
The introduction of free health care in one of the world's poorest countries – a country with only 80 physicians for its six million people – has undoubtedly saved thousands of lives.
The improvement in Sierra Leone's child-mortality rate is among the five fastest in the world over the past decade. More than half of births now take place in a government hospital or clinic, and child mortality has fallen by more than 50 per cent.
Doctors and nurses at Princess Christian Maternity Hospital remember what it was like before 2010. Of the pregnant women who were admitted to the hospital, nearly half ended up dying – largely because they delayed their arrival until their complications had become desperate. They were afraid to face the demand for payment unless they had severe complications – by which time it was often too late.
The cost of admission was less than $5, but additional fees were imposed for every drug and every day of their stay. "Most people would run away," Mbalia Conteh, chief pharmacist at Prince Christian said. "They would discharge themselves."
Today, without medical fees to worry about, women are flocking to the maternity hospitals and clinics to give birth. Hospital wards are crowded and the annual number of deliveries at Princess Christian has soared from less than 1,000 to about 5,400 in the past two years.
"We're able to save many more patients now," said Edward Emuveyan, an obstetrician at Princess Christian. "If a patient has a hemorrhage or infection, the chances of dying are a lot less."
Health experts are hoping that Sierra Leone could be a model for solving the global crisis in maternal and child health – a top priority for Canada since 2010, when it helped mobilize $5-billion for maternal health at the G8 summit in Muskoka, Ontario.
The principle of free health care is a sharp break from earlier ideology. In the 1980s, under the advice of United Nations health experts, many African nations pledged their support to "cost recovery" – a system of user fees in hospitals. Their leaders thought the user fees would generate money to fix their badly underfunded health systems.
But the user fees were a failure. They were widely criticized, they failed to solve the funding problems and they created a new barrier to health care. Today, even the World Bank has given up its advocacy of user fees in the developing world.
To charge the poor even a few cents for medical services is "a death sentence for millions," said former British prime minister Gordon Brown, one of the driving forces behind the free-health-care campaign. He authorized $5.3-billion in British financing in 2009 to help introduce free health care in African countries, and the program soon took off.
At least 10 African countries have now moved to some form of free health care in recent years, and others are introducing low-priced insurance schemes. Some, such as Burundi, have reported an impressive rise in the number of hospital births after eliminating fees.
The most spectacular results have been in Sierra Leone, where the challenges were steepest. But now the country must battle to keep the new system afloat.
"Our resources can't support the explosion in the number of patients," Dr. Emuveyan said. "If we had antibiotics regularly, we could save a lot more lives. Instead, we have to ration our drugs. We have no alternative."
One drug, used in Caesarian sections, has been out of stock for more than eight months, and only the skill of the medical staff is preventing disaster in the surgery room, said Mbalia Conteh, chief pharmacist at Princess Christian Maternity Hospital.
Sierra Leone is heavily dependent on donors such as Britain and the UN children's fund, Unicef, to finance the free-health-care project. But the donors can't pay for it forever and nobody knows whether the government can afford to take over the cost.
"It's very expensive," says Phyllis Ocran, a supply-chain specialist at the Unicef office in Sierra Leone. "Who's going to fund it? Even for a small target population, we are struggling."
The sudden availability of free medicine has led to theft and corruption – or "leaks in the supply chain," as Unicef euphemistically calls it. Ensuring a reliable supply of medicine has been "one of the biggest struggles" of the project, a Unicef report concluded.
At the entrance of the Princess Christian hospital, patients are urged to contact the police or the anti-corruption commission if they see anyone trying to profit from the free drugs. "Do not sell, buy or misuse free-health-care drugs," a large billboard warns the patients.
The government is introducing new controls on its drug supplies to discourage corruption. Some supplies were halted for several months last year while the new rules were introduced. But this, too, can endanger patients. "If you're so afraid of abuse, you can unwittingly cause problems and someone who needs medicine can die," Dr. Emuveyan said.
Another problem is the lingering influence of profit-making private clinics. When their patients switch to the new free system, they expect the same kind of care – including the same over-prescribing of drugs – even if the hospitals try to discourage it.
Fanta Sillah, a hairdresser in Freetown, gave birth to five children in private clinics. When she went to Princess Christian to deliver her sixth child, she continued to buy the useless bottles of "blood tonic" that the private clinics had always marketed to her.
"It's a waste of your money," Dr. Emuveyan told her as he did his hospital rounds. "If you eat good food, you don't need a tonic. It won't do any good."
Lying in her hospital bed with her newborn baby, Ms. Sillah scoffed at the doctor's advice. "He was just giving his opinion," she said. "Let him talk."