The government of Sierra Leone aims to achieve universal healthcare coverage through scaling up community health workers and increasing funding. However, the national health system remains underfunded after being devastated by Ebola. This proposal suggests leveraging private sector funding through IDA's Private Sector Window to close the $11 million annual funding gap for community health workers. Specifically, it proposes using blended financing from IDA and other donors to fund start-up costs and initial insurance premiums. The government would also increase domestic funding for health and promote national health insurance and community-based insurance schemes. This would crowd in private sector funding to develop healthcare providers and insurance programs.

1. Solution to Unlock Financial Opportunities in Sierra Leone to
Finance Community Health Workers and Universal Healthcare
Coverage
Integrating International Development Association’s Private
Sector Window
By
Dr Peter Kamunyo Gathege
World Bank Group’s Massive Open Course (MOOC)
Financing For Development: Unlocking Investment Opportunities
Final Project

2. Target Audience
• Target audience is the Government of Sierra Leone and IDA: to
achieve SDG 3, Good Health and Well Being, is a daunting task
especially in the wake of Ebola which decimated the National Health
Service and dwindling donor aid. The government will have to
increase healthcare funding through innovative financing and tap into
the vast resources available in the private sector for development
goals. In order to achieve universal health coverage it is imperative to
scale-up community health workers as front line workers and to
increase public funding, leverage and catalyze private sector
investment in healthcare financing and insurance.

3. Sierra Leone: Country Brief
• Population (2008) 5.1 million
• Per capita GDP (PPP, Int. US$, 2004)
790
• Economic growth (2006) 7%
• Health expenditure per capita (2007)
7.5 US$
• Health expenditure from development
partners 5.9 US$
• Total health expenditure (2007) 2.4 %
of GDP
• WBG CPIA - 3.267 AfDB - CPIA3.310
Harmonized Average - 3.29

4. The Problem
• The national health service, which was decimated by Ebola remains
understaffed, underfunded, and often unable to reach those most in
need of care.
• "Health care in Sierra Leone is principally financed through private, out-
of-pocket payments (69 per cent) – most of these on medicines. Public
spending is financed partly through the consolidated fund (22 per cent)
and partly by external project based assistance (78 per cent).
Consolidated funding per capita has fallen since 2003 from around $4 to
just over $1.5.”
Maternal and Child Health posts are the first level
of contact on the ground and are located in smaller
towns of with populations between 500-2000.
Much of the health care infrastructure was
decimated during the Civil War and the health
service is still in the process of being organised with
hospitals and staff being trained.

5. What are the reasons that the government, official
aid provider or private sector would want to
participate?
• All medical care is generally charged for in Sierra Leone and is provided by a
mixture of government, private and non-governmental organizations (NGOs) and
this is not sustainable.
• President Ernest Bai Koroma has made community-level care the centerpiece of
the country’s Recovery Plan in an effort to strengthen Specifically, he hopes to
strengthen Sierra Leone’s CHW network of 15,000 health workers by providing
them with a more robust package of training to support the RMNCH health
agenda, stronger supervision and monitoring, and financial and non-financial
incentives.
• There is a very strong political will in the government to establish social health
insurance and the population is willing to pay for quality health care. Particular
emphasis is placed on designing a universal, unitary national health scheme that
covers the whole population including the poor. The process is strongly supported
and followed up by His Excellency the President of Sierra Leone.

6. Main obstacles currently standing in the way
of unlocking financial opportunities?
• Revenue generation: the ability to raise sufficient funds; The proposed CHW expansion and
program improvement will require an estimated $18 million for year 1 and $11 million for
subsequent years, the MOHS has raised year one funding, the outer years remain predominantly
un-funded.
• Pooling: the appropriate sharing of risks and management of funds;
• Purchasing: the active purchase of quality services from health-care providers. All of these
functions need to be fulfilled,
• Efficiency, equity, feasibility and sustainability; Further work by the MOHS is additionally needed to
ensure that Year 1 funding is equitably distributed across the country, with spending tracked.
• Capacity of the administration to effectively manage a programme, because for the first time,
through IDA PSW, some of the funding will flow directly through the MOHS, while other funding
will flow through NGOs, requiring significant coordination and reporting efforts.
• Timely and adequate monitoring and external evaluation.
• Financing arrangements on provider payments and incentives for doctors and nurses to stay in the
country,

7. Solution
Increase health funding THE and %tax/GDP
Remunerate CHWs
Grant fund,
training
Human capital
bonds
Educate
•Improve
health
Sell
commodities
•Affordable
medical
products
•earn
Distribute
community
insurance
•Financial
protection
•Earn
commission
Crowd in funding,
private + others

8. Solutions Summary
• In order to achieve universal health coverage SGD 3, the Government of Sierra Leone is scaling up
community health workers as front line workers. This requires to increase public funding, leverage and
catalyze private sector development funding in order to meet the financial gap of USD 11 million for years
2018 and beyond.
• In addition, to remove the financial burden by promoting the National Insurance Scheme where by working
population pays and the indigents are supported, as well as promoting community based insurance
schemes.
• To unlock this, blended financing will be sustainable route.
• The proposal is to get IDA and other multilateral donors as well as MDBs to fund the set up and training
costs of the proposed 15,000 CHWs as well as funding for the initial premiums for the indigents. This FDI
could also be used to cover for the initial loss ratios of the insurance schemes as they work towards
realizing critical mass and making them profitable taking advantage of the IDA private sector window
funding directly to private sector players. IDA PSW could also be used to finance private healthcare
providers to set up and increase availability of services
• The Government to have policies that are enabling for the private sector to thrive, increase funding for
health from the meagre 2.4% of GDP closer to the proposed Abuja Declaration figure of 15% of GDP.
Domestic resources can be mobilized also by increasing the %tax to GDP ratio, and also by making it easy
for remittances from the large number of migrants who left Sierra Leone during the period of conflict.
• The community health workers would be tasked with education as well as distribution of health
commodities and the insurance schemes in addition to identifying those most in need in the community.
• This would catalyse private funding for development of private health institutions who would also be
providing services to the various medical insurances

9. References:
• Assessment of Health Insurance Options for Sierra Leone Assessment, conceptual
remarks and recommendations International Labour Office Social Security
Department Geneva, September 2009
• Innovative Finance for Development A Commonwealth Toolkit: Nils Bhinda,
Samantha Attridge and Sheena Sumaria
• Strengthening Primary Health Care through Community Health Workers:
Investment Case and Financing Recommendations JULY 2015
• Country Fact Sheet Republic Of Sierra Leone (June 2014)