NR 561 Week 4 Program Closure Case Study Example

Case Study Analysis: What Happened to a District Maternity Waiting Home and Referral Fund in Sierra Leone After the Last Grant Payment, Component by Component

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College of Nursing, Chamberlain University

NR 561: Addressing Global Health Disparities

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Month Day, Year

Case Study Analysis: What Happened to a District Maternity Waiting Home and Referral Fund in Sierra Leone After the Last Grant Payment, Component by Component

The Case and Its Terms

The program examined here is a composite drawn from common designs in West African maternal health projects. A U.S.-based nonprofit, called Riverline Health Partners in this paper, signed a three-year agreement with the District Health Management Team of a coastal district in Sierra Leone, called District K. The agreement ran from January 2021 to December 2023 and funded three things: a 12-bed maternity waiting home beside the district hospital, a referral fund that paid for motorbike and boat transport from outlying clinics, and a stipend for two midwives assigned to the home.

The published grant terms were plain. Funding would end on 31 December 2023. The District Health Management Team would "assume responsibility for continuation," with no named budget line, no transfer schedule and no successor funder. The launch announcement spoke of a lasting legacy. The agreement spoke of an end date. This analysis argues from the agreement.

Why the Program Made Sense

The design addressed a real gap. In Sierra Leone, women in remote areas face long and costly journeys to emergency obstetric care, and post-Ebola research found that distrust of facilities and the cost and difficulty of reaching them kept women from delivering in hospital (Theuring et al., 2018). The 2010 Free Health Care Initiative had removed fees for maternal care but not the cost of getting there, and access gaps persisted across rural areas served by a single district team (Vallières et al., 2016). A waiting home and a transport fund target exactly the distance that free care leaves untouched.

The program also fit national policy on paper. Referral from peripheral units to the district hospital was already the district's responsibility, and the waiting home sat on hospital land. What the design did not do was ask which of those responsibilities the district could pay for once the grant ended.

Component One: The Midwife Stipends

The two midwives were already on the government payroll. The stipend added roughly a third to their monthly pay in return for living at the home and covering nights. When it ended in December 2023, both remained employed by the Ministry, but one transferred to a town clinic within four months, and night coverage at the home stopped. The stipend had bought a schedule, not a post, and the schedule left with the money.

Component Two: The Referral Fund

The fund paid per trip. It had no endowment and no line in the district budget. In the final quarter, Riverline front-loaded payments to clear outstanding claims, so transport continued briefly into January 2024. After that, the fund closed. Outlying clinics returned to the earlier practice of asking families to pay riders, and referral numbers fell to roughly their pre-program level by mid-2024.

Component Three: The Building and Its Consumables

The waiting home building belonged to the district hospital, so it survived. Its consumables did not. Mattresses, mosquito nets, cooking fuel and a small food allowance for waiting women had all come from the grant. By late 2024 the building served as overflow storage for the hospital pharmacy, with three of its 12 beds still in place.

Component Four: Data and Trained People

Riverline had paid a data clerk to keep a register of every woman admitted, her clinic of origin and her birth outcome. The register survived because the clerk was a hospital employee who kept the book on a shelf and continued entries for women who still arrived on their own. Training also survived in part: 14 community health workers had been trained to identify danger signs and call for referral. They kept the knowledge but lost the transport fund that made the call useful.

Who Explained the Closure

Riverline sent a closing letter and a final report to its donors. The person who explained the closure to families was the hospital's senior midwife, who had not signed the agreement and had no say in its terms. This is a common pattern in externally funded programs: the party that closes a service is rarely the one that answers for it locally (Pfeiffer et al., 2008).

Evidence of the Aftermath

This analysis does not reason about consequences from the founding documents alone. The aftermath was traced through three sources available in the composite case: the hospital register, which recorded admissions from outlying clinics month by month before, during and after the program; the district's monthly clinic returns, which report women held overnight at peripheral units; and interviews with the senior midwife and two community health workers in 2024. The register shows admissions from the river clinics rising in the first year of the referral fund and falling back within six months of its closure. The clinic returns show the same pattern in reverse for overnight holds. The interviews explain the mechanism: families again had to find money for a rider, and many waited until morning.

What Survived and Why

Two things continued, the building and the register. Both survived for the same reason: they were owned or staffed by the hospital before Riverline arrived. Everything that existed only because of the grant, the stipend, the fund and the consumables, ended with it. This is consistent with work on program sustainability, which argues that continuation depends on fit with the host system's resources and ownership from the start rather than on intentions announced at the end (Gruen et al., 2008).

Design, Not Effort

The staff in District K worked hard to the last week of the grant, and the program improved access while it ran. Effort was never the issue. The closure was written into terms that funded recurring costs, salaries, transport and food, with three years of nonrecurring money and named no successor line. A two-year or three-year grant on a service that needs a permanent budget was always going to end this way.

Implications

Two design lessons follow. First, recurring costs should either be phased onto the district budget across the grant, with a schedule written into the agreement, or not be funded at all. Second, components should be attached to existing owners from the start, as the building and register were. Proposing a new transport fund on the same terms would repeat the case. Any successor design must say from the outset which budget pays for the third year and beyond.

References

Gruen, R. L., Elliott, J. H., Nolan, M. L., Lawton, P. D., Parkhill, A., McLaren, C. J., & Lavis, J. N. (2008). Sustainability science: An integrated approach for health-programme planning. The Lancet, 372(9649), 1579-1589. https://doi.org/10.1016/S0140-6736(08)61659-1

Pfeiffer, J., Johnson, W., Fort, M., Shakow, A., Hagopian, A., Gloyd, S., & Gimbel-Sherr, K. (2008). Strengthening health systems in poor countries: A code of conduct for nongovernmental organizations. American Journal of Public Health, 98(12), 2134-2140. https://doi.org/10.2105/AJPH.2007.125989

Theuring, S., Koroma, A. P., & Harms, G. (2018). "In the hospital, there will be nobody to pamper me": A qualitative assessment on barriers to facility-based delivery in post-Ebola Sierra Leone. Reproductive Health, 15(1), Article 155. https://doi.org/10.1186/s12978-018-0601-9

Vallières, F., Cassidy, E. L., McAuliffe, E., Gilmore, B., Bangura, A. S., & Musa, J. (2016). Can Sierra Leone maintain the equitable delivery of their Free Health Care Initiative? The case for more contextualised interventions: Results of a cross-sectional survey. BMC Health Services Research, 16, Article 258. https://doi.org/10.1186/s12913-016-1496-1