Assessing healthcare affordability under the free healthcare programme in Sierra Leone

Sierra Leone’s Free Healthcare Programme, primarily implemented through the Free Healthcare Initiative, aims to eliminate user fees for priority groups and improve access to essential services. However, high out-of-pocket costs persist, indicating ongoing affordability and financial protection challenges. This study integrates data from government financing records and household surveys to evaluate healthcare affordability under the programme and recommend policy reforms, in line with WHO guidance and the updated SDG 3.8.2 standard (United Nations Statistics Division, 2025; WHO, 2025a). Data sources include the National Health Accounts 2019-2020 (MoH, 2023), the Digital Health Roadmap 2024-2026 (MoH, 2024), the UN Common Country Analysis 2023 (UN Sierra Leone, 2024), the National Health Compact 2025-2030 (Government of Sierra Leone, 2025), Auditor-General reports (Audit Service Sierra Leone, 2024, 2025), and recent studies on catastrophic spending in Freetown’s informal settlements (Fullah et al., 2025) and public health system redistribution (Gabani et al., 2024). NHA data indicate that out-of-pocket payments accounted for 52.9% of current health spending in 2019 and 52.3% in 2020, with donors contributing 34.0% and 36.2%, and the government 13.5% and 16.8% (MoH, 2023). Total health spending increased from SLL 3,420.88 billion in 2019 to SLL 4,184.50 billion in 2020. The Freetown household study found that 57% of households seeking care outside their communities incurred catastrophic costs, with the poorest group most affected (89%) compared to the wealthier group (12%) (Fullah et al., 2025). These challenges are linked to shortages of medicines and diagnostics, additional costs such as transport, fragmented funding, and inadequate oversight of unofficial charges.