NR 561 Week 2 Disparity Argument Brief Example

Disparity Argument Brief: The April 2010 Free Health Care Package as an Attributable Choice Behind the Gap Between Sierra Leone's and Liberia's Maternal Mortality Ratios

Student Name

College of Nursing, Chamberlain University

NR 561: Addressing Global Health Disparities

Instructor Name

Month Day, Year

Disparity Argument Brief: The April 2010 Free Health Care Package as an Attributable Choice Behind the Gap Between Sierra Leone's and Liberia's Maternal Mortality Ratios

The Gap

Liberia's maternal mortality ratio for 2020 was estimated at 652 for every 100,000 live births, against 443 for Sierra Leone, in the most recent joint United Nations estimates (World Health Organization [WHO], 2023). The two countries border each other, emerged from civil wars in 2002 and 2003, and shared the 2014 to 2016 Ebola epidemic. This brief argues that a measurable part of the difference traces to one choice made in Freetown in 2010, and that the choice could have been made differently.

Two caveats limit the argument. First, both figures are modeled estimates with wide uncertainty, so the brief treats the gap as real in direction but not exact in size. Second, many things shape maternal survival, and the brief does not claim that one decision explains all of the difference. It claims that one decision explains enough of it to matter and that the decision is attributable.

Conditions That Cannot Carry the Argument

Poverty, terrain, a long war and a high disease burden describe both countries equally well. A condition shared by both cannot explain why they differ. Each is also something no one signed, which means that even if it did explain the gap, nobody could be asked to undo it. The brief therefore sets these aside, not because they are unimportant, but because they do not answer the question asked.

The Choice

The decision was taken in April 2010 by Sierra Leone's government, acting through the Ministry of Health and Sanitation and announced by the President, launched the Free Health Care Initiative. Under it, mothers who were pregnant or breastfeeding, along with every child below age five, stopped paying user fees at government facilities (Edoka et al., 2016). Fee exemption alone has a mixed record across Africa, and removing fees without replacing lost facility income or securing drugs and staff can leave clinics worse off (Gilson & McIntyre, 2005). The Sierra Leone decision was different in its packaging. The initiative was tied to a substantial increase in health worker pay, a verified payroll that removed absent and nonexistent workers, and monitoring of attendance, all prepared before launch with substantial donor finance and technical support (Donnelly, 2011; Witter et al., 2016).

The choice therefore has a named body, the Government of Sierra Leone through its Ministry of Health and Sanitation, a date, April 2010, and a set of instruments: the fee exemption policy, the revised salary scale and the payroll verification.

The Chain From Choice to Outcome

The brief documents three links rather than asserting one leap.

Link 1, staff present. Witter et al. (2016) drew on document review, interviews with government, donor and NGO staff, Ministry personnel data, and a survey of 312 health workers. They reported substantial increases in the number of health workers on the payroll and in their pay, particularly for higher cadres, together with reported reductions in absenteeism and attrition and, where data existed, increased outputs per worker.

Link 2, women attending. Using two nationally representative surveys, Edoka et al. (2016) found substantial increases in the use of key maternal services in public facilities among expectant and recent mothers after the initiative, while cautioning that the increases may have been transient.

Link 3, survival. Facility use with skilled staff present is a recognized route to fewer maternal deaths, because obstetric hemorrhage, eclampsia and obstructed labor can be treated only where trained staff and supplies are available. The brief cannot measure this last link directly in national data, and it says so. It relies on the first two links to make the third plausible.

What Liberia Did Differently

This brief does not argue that Liberia did nothing. Liberia's post-war health system expanded basic services, but rural access to emergency obstetric care remained thin; a 2008 survey in rural Nimba County found that only about 27% of respondents could reach basic emergency obstetric care at their nearest facility, compared with all respondents for malaria treatment (Kruk et al., 2010). The contrast that matters for this brief is narrower: Sierra Leone made one national decision that tied free maternal care to the pay and presence of the staff who would deliver it.

Where the Evidence Is Weak

A careful reader could press on three points. The surveys used by Edoka et al. (2016) span the launch but cannot separate the fee change from the staffing change, so the brief credits the package rather than either part. The Ebola epidemic interrupted both countries' gains, and its uneven toll on health workers complicates any comparison of post-2015 trends (Evans et al., 2015). Finally, the 2020 estimates might be revised. None of these points removes the attribution; each narrows it.

Anticipated Objections From the Body Named

An official of the Ministry of Health and Sanitation reading this brief might object that the government deserves credit for more than one decision, and that the brief reduces a decade of rebuilding to a single month. The objection is fair, and the brief does not dispute that other decisions mattered. It selects the 2010 package because it is the clearest instance of a choice with a date, a decision maker and instruments that can be checked. A donor official might object from the other side that the package was designed and financed with outside support, so attribution to the government is overstated. The record supports a shared attribution: the decision to make maternal care free was announced and owned by the government, while preparation and early finance were shared with donors (Donnelly, 2011). Either way, the arrangement was chosen by identifiable parties, and that is the point the brief needs to establish.

Reversibility

The arrangement is live, which is why the brief matters. The 2010 package depends on recurring money: salaries, drug supply and the monitoring that keeps the payroll honest. Witter et al. (2016) warned that the challenge would be sustaining attention once the initiative became routine. The party that set the package up was a government working with outside financiers. The party that holds authority over it today is the Ministry of Finance, through the annual budget lines for the health wage bill and for essential medicines, together with the donors whose pooled funds still buy much of the drug supply. If the drug line is underfunded, informal charges return at the counter, and the fee exemption becomes a policy on paper only.

That makes the brief's final point simple. The choice that opened part of the gap was made by a named government in 2010, and the choice that keeps it open is made again every budget year by a named ministry. Both could have gone differently.

References

Donnelly, J. (2011). How did Sierra Leone provide free health care? The Lancet, 377(9775), 1393-1396. https://doi.org/10.1016/S0140-6736(11)60559-X

Edoka, I., Ensor, T., McPake, B., Amara, R., Tseng, F.-M., & Edem-Hotah, J. (2016). Free health care for under-fives, expectant and recent mothers? Evaluating the impact of Sierra Leone's free health care initiative. Health Economics Review, 6(1), Article 19. https://doi.org/10.1186/s13561-016-0096-4

Evans, D. K., Goldstein, M., & Popova, A. (2015). Health-care worker mortality and the legacy of the Ebola epidemic. The Lancet Global Health, 3(8), e439-e440. https://doi.org/10.1016/S2214-109X(15)00065-0

Gilson, L., & McIntyre, D. (2005). Removing user fees for primary care in Africa: The need for careful action. BMJ, 331(7519), 762-765. https://doi.org/10.1136/bmj.331.7519.762

Kruk, M. E., Rockers, P. C., Williams, E. H., Varpilah, S. T., Macauley, R., Saydee, G., & Galea, S. (2010). Availability of essential health services in post-conflict Liberia. Bulletin of the World Health Organization, 88(7), 527-534. https://doi.org/10.2471/BLT.09.071068

Witter, S., Wurie, H., & Bertone, M. P. (2016). The free health care initiative: How has it affected health workers in Sierra Leone? Health Policy and Planning, 31(1), 1-9. https://doi.org/10.1093/heapol/czv006

World Health Organization. (2023). Trends in maternal mortality 2000 to 2020: Estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. https://www.who.int/publications/i/item/9789240068759