Free Health Care for Under 5 Year Olds Increases Access to Surgical Care in Sierra Leone: An Analysis of Case Load and Patient Characteristics
In April 2010 Sierra Leone launched a nationwide program that provides free health care to all pregnant and lactating women and children under 5 years old. This study evaluates the effect that the free health-care program had on pediatric surgical activities of Connaught Hospital.
The study period was defined as the 20 months before and after April 27, 2010, the start date of the free health-care program. Data on age, gender, diagnosis, and procedure for patients under 5 years of age and the total number of operations were collected from the Connaught Hospital operating room logbook.
The number of operations on children under 5 increased by 500 %, from 42 to 210 cases. This increase was significantly larger than the 17 % increase of 1,393–1,630 seen with operations for patients 5 years and older (p < 0·01).
The decision by the Sierra Leone President to institute a program of free health care for children under 5 has resulted in an increased number of pediatric surgical cases at Connaught Hospital. Efforts should be undertaken to provide additional supplies and equipment and to develop training programs for surgeons and support staff to care for the children in need of surgical care.
In an effort to improve the lives of the world’s poorest populations, the United Nations created the millennium development goals (MDGs). The MDGs, introduced in 1991, comprise a set of ten targets aimed at reducing poverty, improving education, and providing access to clean water and health care. The aims of MDGs 4 and 5 are to reduce the under 5 mortality rate by two-thirds and the maternal mortality rate by 75 %, respectively, between 1990 and 2015 .
Although no MDG specifically mentions surgery, a case has been made that without improvements in the capacity to provide surgical care, the targets for MDGs 4 and 5 will not be reached [2, 3]. With respect to MDG 4, although most childhood deaths in low- and middle-income countries are caused by infections, there are also a significant number of deaths that result from trauma, malignancies, and congenital conditions, many of which can be diagnosed, treated, or palliated with surgical care .
As one of the world’s least developed countries, Sierra Leone was ranked 180/187 on the UN Development Index for 2011 . With an estimated per capita GDP of US$734 and an average life expectancy of 47.8 years, the country also has one of the world’s highest under 5 (174/1,000) and infant mortality rates (114/1,000) . In April 2010, in an effort to improve the health of the population of 6 million, the President of Sierra Leone launched a nationwide program that provides free health care to all pregnant and lactating women and children under 5.
This program was heralded as a great success , and in a preliminary analysis, it appeared to have led to an increase in pediatric surgical cases at Connaught Hospital, the main tertiary-care referral center in the country . For this study we sought to further analyze the volume and characteristics of the pediatric surgical cases undertaken specifically for under 5 children and assess changes that occurred following the implementation of the free health-care program. The data collected would be useful in planning interventions and defining resource needs.
This retrospective observational study evaluated pediatric surgical activities in the main operating rooms of Connaught Hospital. The study period was defined as the 20 months before and after April 27, 2010, the start date of the free health-care program.
Connaught Hospital, in the Sierra Leone capital city Freetown, is the country’s largest health-care facility, with 327 beds. It is also the ministry of health and sanitation (MOHS) tertiary-care referral center for medical and surgical conditions. Although a pediatric hospital is present in Freetown, no procedures are undertaken there and all pediatric surgical cases are referred to either Connaught Hospital or a nongovernmental hospital, which also provides free surgical care.
Inclusion criteria and analysis
All patients under 5 years of age who were operated on in the main operating rooms of Connaught Hospital were included in the study. Data on age, gender, diagnosis, and procedure for patients under 5 years of age and the total number of operations performed were collected from the handwritten entries in the surgical logbook kept outside the operating rooms. Age was recorded in whole numbers. The number of procedures performed by visiting international surgeons was also recorded. A χ2 test was used to assess the significance of the increased number of under-5 cases.
Comparison of operations on children under 5, 5 and above, and total, and average age and sex distributions for the 20 months before and 20 months after start of free health-care program, Connaught Hospital, Freetown, Sierra Leone
Before free health care (%)
After free health care (%)
p < 0.01
Operations by international teams (under 5)
Average age (under 5)
Total males (under 5)
Total females (under 5)
The average age of patients under 5 who underwent surgery was 1.8 years before the program and 2.1 years after the program started. Overall, males outnumbered females before the program at 20:1, but this decreased to 6.5:1 after the start of the program (Table 1).
Comparison of the number of surgical cases on under 5 year olds by diagnostic category before and after the start of the free health-care program at Connaught Hospital, Freetown, Sierra Leone
Before free health care (%)
After free health care (%)
Ears, nose, and throat
When examining specific procedures, inguinal hernia repair was the most common: 26 (61.9 %) before and 128 (60.9 %) after. After the start of the free health-care program, a larger number of foreign body removals (n = 14), umbilical hernias (n = 10), sequestrectomies (n = 8), incision and drainage of abscesses (n = 6), and post-burn contracture releases (n = 6) were undertaken.
Prior to the free health care for the under 5 year olds, international visiting surgeons performed 11 operations (26.2 %) in this surgical patient population at Connaught Hospital, including insertion of three VP shunts; after the start of free health care, visiting teams performed 30 operations (14.2 %).
This study highlights the increase in the volume of pediatric surgery at Connaught Hospital in Sierra Leone that was observed after the initiation of a nationwide program to provide free health care for children under 5 years old and pregnant and lactating women. The results show that the total number of operations for patients 5 years old and above increased by 17 % between the two 20-month study periods, while the number of operations performed on children under 5 increased by 500 %.
Although the data represent an absolute increase of only 168 cases, it is important to view this increase in the context of how surgical care is delivered in Sierra Leone. Prior to the institution of the free health-care initiative, under-5 surgical procedures were conducted in a manner similar to that of other procedures. Patients arrived with a problem and were seen by a clinician. If it was determined that a surgical procedure was needed, a prescription was written for supplies such as sterile gloves, suture, gauze, and antibiotics. The patient or relatives were then responsible for buying these supplies from an outside pharmacy; once they returned with the supplies, the procedure was undertaken.
After the initiation of the free health-care program, Connaught Hospital and more commonly the surgeons were obligated to provide the material necessary to undertake the procedure: both elective and emergency cases. As Kingham et al.  documented in 2009, there is a massive deficiency of surgical capacity in Sierra Leone with its limited supplies, equipment, and surgical specialists.
One observation of this study is that while some procedures were performed by international visiting surgeons who brought their own supplies, the majority of the increased caseload was undertaken by local Sierra Leone surgeons who were obligated to provide the necessary supplies. During the study period, the absolute number of pediatric cases performed by visiting surgeons increased from 11 to 30; however, the percentage of under-5 cases done by visiting surgeons decreased from 26.2 to 14.2 %.
After the start of the free health-care program, a large number of inguinal hernia repairs were performed. Before the program there were no hernia repairs or operations to remove a foreign body; however, after the start of the program these procedures were common. It is unclear what happened with these cases earlier; however, it is unlikely that the increase in number indicates an increase in the prevalence. It might suggest a backlog of cases, which is supported by the change of average age from 1.8 to 2.1 years.
The relatively high number of urology cases possibly reflects the presence of a urologist at Connaught Hospital, resulting in clinicians referring these types of cases. The urologist was present in the 20 months before and after the introduction of the free health-care program and therefore is unlikely to be a confounder. Relatively few pediatric trauma cases were undertaken and this may reflect the presence of a nongovernmental hospital that specializes in emergency surgical care located near Freetown. This hospital often has international surgeons and also offers free health care.
Limitations of the study include the retrospective nature of the study design, the limited variables, and no means of verifying missing registration of cases. The simplistic medical records system of a handwritten operating room logbook limits the ability to thoroughly analyze patients under 1 year of age, specific procedure details, and postoperative morbidity and mortality. The need to improve data collection and the hospital’s medical records system has been identified as a priority. Ideally, international donors will recognize the benefits to patient care and research and assist with such projects.
With the increasing number of pediatric surgical cases in Sierra Leone, there should be an effort to train local surgeons to perform many of the more technically challenging procedures like the insertion of VP shunts and congenital atresias. In our data, these procedures were performed by visiting international surgeons; however, in other low-income countries local hydrocephalus programs have been initiated . These types of initiatives should be accompanied by training of the anesthesia and nursing staffs for specific pediatric needs. Surgery will be a success only if training is integrated with adequate, uninterrupted pediatric supplies and equipment. Although gradual improvements have been seen at Connaught Hospital , there is still a lack of sufficient functioning operating theatres, supplies, and postoperative management, and, therefore, the hospital has difficulties providing free health care to those under 5 from a logistical and financial standpoint.
The decision by the Sierra Leone President to institute a program of free health care for children under 5 years old and pregnant and lactating women has been heralded as a success; however, it has also resulted in an increased number of pediatric surgical cases at Connaught Hospital. Efforts should be undertaken to provide additional supplies and equipment and to develop training programs for surgeons and support staff to care for the children in need of surgical care.
Conflict of interest
The authors have no conflicts of interest to disclose.
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