Sierra Leone's Free Health Care Initiative for Pregnant Women, Lactating Mothers and Under-Fives

Sierra Leone launched its Free Health Care Initiative (FHCI) in April 2010, removing user fees for pregnant women, lactating mothers and children under five at public health facilities nationwide, in a country that faced some of the world's highest maternal and child mortality rates after its 1991–2002 civil war.

A peer-reviewed analysis of Sierra Leone Demographic and Health Survey data (Jalloh et al., 2019) comparing 2008 (n=7,374 women) with 2013 (n=16,658 women) found institutional deliveries rose from 27% to 57%, antenatal care visits (4+) rose from 51% to 75%, and complete postnatal reviews rose from 8.3% to 41.4%. WHO's Africa regional office reports Sierra Leone's maternal mortality ratio fell 74%, from 1,682 to 443 deaths per 100,000 live births, between 2000 and 2020, with facility-based deliveries by skilled attendants exceeding 80% by the early 2020s, up from 54% in 2010.

The same peer-reviewed evaluation found wealth-related inequity in institutional delivery widened over the study period, with richest-quintile women reaching 72.2% institutional delivery by 2013 versus 50.4% among the poorest quintile, indicating free care alone did not close access gaps driven by education, rural residence and other structural barriers. Sierra Leone still falls short of the SDG target of 70 maternal deaths per 100,000 live births.