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Health Care Provision in Sierra Leone: Answering the trend toward centralization

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Introduction

Coming out of an eleven year long civil war, Sierra Leone's government battles limited resources and a

damaged infrastructure while trying to institute a functioning democracy with efficient service delivery. Sierra

Leone's health care system, managed, financed, and implemented by the Ministry of Health, faces similar challenges

in attempting to evenly distribute and deliver public services. While each district has a government hospital and the

ministry attempts to appropriate resources across the country, service distribution is far from uniform and may be to

the benefit of a few elite rather than to the majority of citizens. Even with the institution of the Free Health Care

Initiative, providing free basic medicine and care to pregnant and lactating women and children across the country,

there are large sections of the population – the majority of which are female, poor, and live in rural areas – who are

effectively cut out of the redistribution network and who have disproportionately low access to public services. This

paper attempts to answer the question of why Sierra Leone's government and public service provision remains

centralized in Freetown, and what government institutions exist that allow leaders to stay in power and consolidate

resources despite this narrow distribution of benefits. There are several theoretical reasons for how elite maintain

their positions of power and are able to enrich themselves at the public's expense. Through research of Sierra Leone's

health care infrastructure, political system, and societal attributes, this paper shows that the Sierra Leonean

government's failure to evenly distribute resources across the country is a symptom of clientelistic practices and a

direct result of a principal-agent relationship failure due to lack of oversight, alarm signals, and constraint of

bureaucratic power.

In the next section of this paper, the political science theories of clientelism, selectorate theory, and

principal-agent theory will be explained and discussed. The third section will move on to Sierra Leone as a case

study, detailing the health care system and political situation based on my field research and interview notes. A

fourth section will discuss the implications of this research and a fifth section will conclude.

Approaches to Elites and Governance

Clientelism:

Clientelism often refers to to system of governance in which material favors are offered to a population in

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return for political support at the polls. Also known as a patron-client system, clientelism specifically describes a

system of conditional loyalties in which individuals of unequal power are linked together by an exchange of favors.1

While clientelism is often associated with class identity, in societies where class identity is low, clientelism is often

associated with ethnicity.2 Often characterized by the representation of narrow corporatist and local interests, there

often is no functional system of checks and balances for political elite. Most attractive when society has low

productivity, high inequality, and hierarchical social relations, clientelism is characterized by the redistribution of

public goods to favored sections of the electorate.3 Scholars often define clientelism as having the following

characteristics,

“(a) the relationship occurs between actors of unequal power and status; (b) it is based on the principle of reciprocity; that is, it is a self-regulating form of interpersonal exchange, the maintenance of which depends on the return that each actor expects to obtain by rendering goods and services to each other and which ceases once the expected rewards fail to materialize; (c) the relationship is particularistic and private, anchored only loosely in public law or community norms.”4

More specifically, in clientelistic systems, authority is granted on a personal basis and leader's values include

personal enrichment and aggrandizement. Leaders tend to monopolize power, are unaccountable for their actions,

and do not have a direct relationship to their constituency. Policy decisions are not public affairs and procedures are

often hard to follow from an outside standpoint. Additionally, campaigns for political elite are structured around

personalities rather than policy platforms or the candidate's qualification.5

Political clientelism, a patronage-based voter-party linkage in which material goods are offered for electoral

support, is often argued to be inevitable in the modern state.6 This is assumed to be because a state structure's fiscal

and regulatory capacity will always produce discretionary resources that the state agents benefit from personally

1 Derick W. Brinkerhoff and Arthur A. Goldsmith, “Clientelism, Patrimonialism, and Democratic Governance: An

Overview and Framework for Assessment and Programming,” U.S. Agency for International Development Office of Democracy and Governance under Strategic Policy and Institutional Reform (2002): 40.

2 Brinkerhoff and Goldsmith, “Clientelism, Patrimonialism, and Democratic Governance: An Overview and Framework for Assessment and Programming,” 20.

3 Leonard Wantchekon, “Clientelism and voting behavior: Evidence from a Field Experiment in Benin,” World Politics Vol. 55 No. 3 (2003): 400.

4 Brinkerhoff and Goldsmith, “Clientelism, Patrimonialism, and Democratic Governance: An Overview and Framework for Assessment and Programming,” 5.

5 “Political Clientelism, Social Policy, and the Quality of Democracy: Evidence from Latin America,” (paper presented at the conference of the Network of Democracy Research Institutes (NDRI), Quito, Ecuador, November 5-6, 2010: 5).

6 Brinkerhoff and Goldsmith, “Clientelism, Patrimonialism, and Democratic Governance: An Overview and Framework for Assessment and Programming,” 5.

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redistributing (assuming that private redistribution of resources offers a political advantage).7 One of the reasons this

redistribution is possible is because clientelistic societies generally have high levels of presidentialism. Most African

states, while democracies or parliamentary regimes, have most of their constitutional and de facto powers

concentrated in the president.8 Powers including those of position appointment, control of the national budget, and

policy implementation are concentrated within the presidential position with little to no oversight. Generally, the

legislatures in these countries are compliant with the executive's wishes and judicial systems are weak and highly

politicized.9 These regimes are not only presidential because of the personal power invested in the president, but also

because the already narrow elite are almost entirely based in the capital city, adding another dimension to an already

highly centralized administrative and judicial system.10 Kitschelt aptly described the main factors leading

presidential societies to be clientelistic:

“First, [polities with strong presidential powers] personalize competition for the highest office and attract ambitious politicians who are often distinguished only by their personal support networks buttressed by personal charisma or relations of clientelism but not by policy programs. Contingent on the electoral system, this promotes personalist-clientelist intraparty factions or a fragmented, clientelist multiparty spectrum. Second, the personalist contest for the presidential office encourages candidates to deemphasize programs and issue programmatically diffuse catchall appeals. Third, elected presidents succeed in becoming powerful players only if they prevent the emergence of a stable, program-based legislative majority that would constrain their control and discretion over the legislative agenda. To do so, they may prefer to govern with shifting legislative majorities constructed by means of side payments to legislators[.] Fourth, because legislators are not responsible for the survival of the presidential government, they are more likely to withdraw support from the cabinet and maintain loyalty to the president only if they receive selective material inducements that permit them to maintain their own clientelist networks.”11

Due to the ensuing weak legislature and electoral system concentrated on a single political figure, polities with

strong presidential powers tend to enforce clientelism within their societies. Clientelism, then, is a natural product of

highly presidential systems. Clientelism is seen to be inevitable in the modern state due to the large amount of

discretionary power and resources to which the president has access.

In clientelist societies with high levels of presidentialism, political systems tend to be largely patrimonial. In

7 Nicolas van de Walle, “Presidentialism and Clientelism in Africa’s emerging party systems,” Journal of Modern

African Studies Vol 41 No. 2 (2003): 312. 8 van de Walle, “Presidentialism and Clientelism in Africa’s emerging party systems,” 299. 9 Nicolas van de Walle, “The Democratization of Political Clientelism in Sub-Saharan Africa,” (paper presented at

the third European Conference of African Studies, Leipzig, Germany, June 4-7, 2009): 6. 10 van de Walle, “Presidentialism and Clientelism in Africa’s emerging party systems,” 310. 11 Herbert Kitschelt, “Linkages between Citizens and Politicians in Democratic Polities,” Comparative Political

Studies 33 (2000): 861.

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1947, Weber first coined the phrase patrimonialism to describe situations in which administrative figures are

appointed by and/or responsible to a singular leader. These appointees traditionally enjoy excessive leeway in their

actions and decision-making, as most actions are informal and off the record. As administrative jobs are some of the

best gifts a leader can offer his supporters, patrimonialism is highly correlated with clientelism.12 In patrimonial

government systems, personnel are responsible only to the head politician, in most cases the president, thus allowing

them to use their government positions for personal income and asset acquisition.13 Public income and resources,

then, are diverted to private interests in part due to the patrimonial nature of societies.

Certain societal factors can also increase the incidence of clientelism. Van de Walle's comprehensive list of

factors contributing to the presence of clientelism and patronage at all levels of society included, “The absence or

narrowness of a public realm in the Western sense, the strength of clan, ethnicity and other sub-national identities,

the predilection for dyadic exchange in primarily rural societies, and the need for mechanisms of ‘social insurance’

in the risky and uncertain environment of low-income societies.” In such systems, clientelism and corruption can be

legitimized by clan-based redistribution as people see it serving a community purpose rather than individual

enrichment. Even though this exchange/redistribution is largely symbolic and societies are often marred with glaring

inequality, clientelism serves to lower the salience of class identities while linking patron with client.14 Thus, societal

factors can aid in the implementation of and conversely be caused by political clientelism.

Unfortunately, clientelism often leads to gross societal inequalities as certain segments of the population are

left out of the redistribution process. Clientelism then becomes a means through which leaders can mobilize political

support and control the electorate while socially and economically excluding rural populations and urban migrants.15

Studies conducted in Benin concluded that rural women may be excluded from the most common forms of

clientelistic redistribution as, generally, they are not part of the elite and patronage jobs are not awarded to them. For

the most part, women instead responded more positively to broad based policy claims and promises of improved

12 Brinkerhoff and Goldsmith, “Clientelism, Patrimonialism, and Democratic Governance: An Overview and

Framework for Assessment and Programming,” 6. 13 Brinkerhoff and Goldsmith, “Clientelism, Patrimonialism, and Democratic Governance: An Overview and

Framework for Assessment and Programming,” 40. 14 van de Walle, “Presidentialism and Clientelism in Africa’s emerging party systems,” 312. 15 Morris Szeftel, “Misunderstanding African Politics: Corruption and the Governance Agenda,” Review of African

Political Economy Vol. 25, No. 76 (1998): 237.

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public health over promises of personal patronage and resource distribution to ethnic populations.16 Thus, clientelism

is particularly damaging to rural women and those not considered as part of the elite. While clientelism may be an

effective tool of the executive to gain control of the electorate, it effectively serves a very small segment of the

population and leads to a decrease in public services as leaders increasingly use state resources to serve the elite

minority.

Selectorate Theory:

A related theory to explain patterns of political institutions and the survival of politicians is selectorate

theory. Selectorate theory analyzes the effects of the size of the selectorate, or the number of people who have a say

in appointing politicians, and the size of the winning coalition, or the minimal set of people whose support the

incumbent needs in order to remain in power. In modern mass democracies, the selectorate is the electorate and the

winning coalition is determined by electoral rules. In autocracies, the selectorate is a powerful group of supporters

and the selectorate is every person with membership to the party system (or military, as it may be). In general, large

winning coalitions coincide with more emphasis on public policy and public goods. Small winning coalitions are

correlated instead with providing private goods (including but not limited to state-granted monopolies, access to

currency, and bribes) to a small group of supporters at the expense of public goods provision.17 Bueno Mesquito et.

al. found that

“income, growth, investment, civil liberties, property rights, peace (meaning the absence of civil or international war), transparency (measured by whether or not polities report economic and tax data), and a host of public health, education and social security measures all increase as our measure of coalition size increases and as our measure of selectorate size decreases. In contrast, corruption (as measured by black market exchange rate premiums, construction as a proportion of the economy, and Transparency International's index) and the extent to which government expenditures and revenues do not match are higher in small [winning coalition], large [selectorate] systems. Coalition and selectorate size also significantly influence the foreign policies of states and the risk of coups, revolution, emigration, immigration and many other factors.”18

In essence, the larger the subset of the population is necessary to elect a leader, the better the public resource

16 Wantchekon, “Clientelism and voting behavior: Evidence from a Field Experiment in Benin,” 419. 17 Bruce Bueno de Mesquita, James Morrow, Randolf Siverson, and Alastair Smith, “Political Institutions, Policy

Choice and the Survival of Leaders,” British Journal of Political Science Vol. 33, No, 4 (2002): 561. 18 Bueno de Mesquita, Morrow, Siverson, and Smith, “Political Institutions, Policy Choice and the Survival of

Leaders,” 584.

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distribution and available opportunities for citizens. The government works for the people electing the leader – thus,

when the public truly elects a leader, government resources go to the public good. In contrast, when a small elite

controls who wins there is more incidence of corruption and private pilfering of goods. Selectorate theory helps to

illuminate which leaders stay in power by analyzing the number of people and reciprocity involved in electing

leaders.

Small winning coalitions have severe consequences for the distribution of private goods and competition.

Assuming the size of the winning coalition is relatively fixed, it follows that the loyalty of coalition members

increases as the size of the selectorate increases. This is presumed to be because if a challenger replaces the current

leader, there is no certainty that members of the current coalition will be included in the challenger's winning

coalition and thus continue receiving preferential treatment. The aforementioned risk of exclusion means challengers

must offer the leader's coalition members much more than the leader provides in order to win their support. The

inverse side of the situation is that the smaller the winning coalition and the larger the selectorate, the easier it is for

incumbents to maintain the loyalty of their coalition members. Additionally, small winning coalitions have

the side effect of encouraging complacency and tolerating corruption as those practices enable leaders and coalition

members to reward supporters and acquire resources. According to authors Bruce Bueno de Mesquita, James D.

Morrow, Randolph M. Siverson and Alastair Smith, nations lacking in infrastructure were especially prone to

tolerance of corruption as collecting taxes to reward supporters is seen to be inefficient relative to allowing the

supporters to expropriate resources for themselves.19 In essence, there are incentives for the “haves” in society to

engage in rent seeking behavior and to maintain control over resources at their disposal, effectively excluding the

“have nots” of society.20 Small winning coalitions benefit a select few in society, leaving the general population

without access to resources and lacking in public services.

Principal-agent Theory:

In order to help explain the relationship between employers and employees, state government and the

19 Bueno de Mesquita, Morrow, Siverson, and Smith, “Political Institutions, Policy Choice and the Survival of

Leaders,” 584 – 662. 20 Todd Landman and Marco Larizza, “Inequality and Human Rights: Who Controls What, When, and How,”

International Studies Quarterly 53 (2009): 719.

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population, and many other hierarchical relationships, agency theory helps illuminate some of the factors and

inherent concerns of such relationships. The principal-agent relationship stems from the idea that an individual or

body of individuals need a task done (the principals), but do not have the information, expertise, or access to

accomplish it. Thus, they contract the task to another individual or body of individuals with decision-making ability

to do the task for them (the agents). Agency theory is meant to explain the relationship between key constituencies in

a state: the power holders, the bureaucracy, and the population. One can apply the principal agent relationship in one

of two ways, in the first, the population holders are the principals and the power-holders are the agents. In the other,

the power holders are the principals who have to monitor the activity of the bureaucracy, or the agents.21 No matter

whom the relationship describes, there are inherent hazards in contracting out work as the motives of the principal

and the agent are naturally different.

Agency costs arise as principals delegate decision making authority to agents as the interests of the

principals and the agents might diverge, incurring transaction costs of monitoring agent behavior and sub-optimal

outcomes for the principal.22 The first principal agent problem is the adverse selection problem. That is, when the

principal needs to hire an agent, the principal has limited information concerning the applicant’s qualifications,

training, and achievements. This is intensified by the fact that the potential agents have reason to overstate their

abilities and qualifications to obtain the job. The second principal-agent problem is that of moral hazard. In other

words, principals and agents have competing self-interests despite the fact that the agent is hired to represent the

principal and that the agents actions affect the principal in some way.23 The third problem is the assumed situation

that the principal can only learn the efforts of the agent at a high cost or with great difficulty.24 While the principal

cannot easily monitor the agent, it is presumed that the results of the agent's actions are observable and inexpensive

to obtain. In order to reduce risks and problems, the principal can make a contract that will provide incentives for the

21 John James Quinn, "Principal-agent Theory," 21st Century Political Science: A Reference Handbook. Thousand

Oaks: Sage Publications, 2011. https://login.ezproxy.carleton.edu/login?url=http://search.credoreference.com/content/entry/sagetfcpolsci/principal_agent_theory/0 (accessed February 14, 2014.)

22 Karen Cook, Trust in Society (New York: Russell Sage Foundation, 2001), 187. 23 “The agent usually wants the most pay for the least amount of work, and the principal wants the biggest reward

(or smallest penalty) with the least payment to the agent.” Quinn, "Principal-agent Theory." 24 Quinn, "Principal-agent Theory."

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agent.25 This contract or payment system ideally works such that the agent will act on the principal's behalf by giving

bonuses to agents for accomplishing tasks relevant to the principal's interests.26 This contract is presumed to endow

the principal with bargaining power over the agent, allowing them to make “take it or leave it” offers.27 Due to

information asymmetries and the principal's inability to oversee agent action, the agent's actions may not be in the

principal's best interest.

There are two types of oversight that principals can potentially engage in to monitor agent behavior. The

first form is police-patrol oversight in which the principal actively and constantly monitors the agent – collecting

information on their behavior, preferences, and outcomes. The other type, fire-alarm oversight, involves external

information about the risks of agency activities. In other words, fire-alarm oversight involves media, regulatory

agency, or citizen reporting of unusual accidents, disasters, or complaints from dissatisfied people. Legislators are

able to save costs with fire-alarm oversight by ignoring all services about which they do not hear any fire-alarm

signals.28 This assumes that the principal may respond to fire-alarm signals by engaging in oversight activity or

employing budgetary and/or legislative controls over the agent.29 30 However, if a legislator cannot learn something

from the fire-alarm signals, the preferences of those raising fire alarms and legislators are not similar, or the

legislator cannot enact oversight or penalties for agent shirking, then the act of delegation from principal to agent is

equivalent to abdication where the will of the people neither constrains for motivates public policy.31 Oversight can

only shape incentives and policy if there is feedback from third-party agencies and legislators have power to enact

sanctions.

25 David Sappington, “Incentives in Principal-agent relationships,” The Journal of Economic Perspectives Vol. 5

No. 2 (1991): 49. 26 Even though the principal is informationally disadvantaged, some argue that they can structure incentives such

that the agent will still act as the principal wants given they had the same information. By manipulating the agent's incentives, the principal attempts to eliminate “shirking” or costs related to competing self interests.

Gary Miller, “The Political Evolution of Principal-Agent Models,” Annual Review of Political Science 8 (2005): 203.

27 Miller, “The Political Evolution of Principal-Agent Models,” 206. 28 Miller, “The Political Evolution of Principal-Agent Models,” 210. 29 Hugo Hopenhayn and Susanne Lohmann, “Fire-Alarm Signals and the Political Oversight of Regulatory

Agencies,” Journal of Law, Economics, and Organization Vol. 12, No. 1 (1996): 197. 30 Some suggest that assuming the principal can effectively carry out legislative and budgetary action against

agents, that the threat will assure agency compliance with principal wishes. Hopenhayn and Lohmann, “Fire-Alarm Signals and the Political Oversight of Regulatory Agencies,” 199.

31 Arthur Lupia and Mathew McCubbins, “Learning From Oversight: Fire Alarms and Police Patrols Reconstructed,” Journal of Law, Economics and Organization Vol. 10, No. 1, (1994): 111.

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Common Problems of Government Health Care Systems in other countries:

While one of the main reasons government intervention in health care is justified is to correct for inequality

in the private sector, government intervention may not treat populations equally. One study in Kerala, India, studying

the effects and structure of the government health system found that in practice, a few individuals in government

make all the decisions. Because of this, government decision-making reflected more on the interests of those few

individuals than of the interests of the community.32 Thus, instead of preventing discrimination against the poor and

rural, discrimination increased. While the government expanded services, the legislators were biased in favor of

urban areas and the financial interests of the health department. In addition, instead of correcting for urban-rural

discrepancies in care, large percentages of the government resources were appropriated to personnel salaries.33 This

pay increase was not dependent on productivity increase. Ultimately, the supply of government services adversely

affected hospitalization services to the rural poor.34

Studies of African health care systems have found health care to follow systematic trends. In general,

although basic indicators of child and infant mortality, immunization coverage, and government funding have

increased over time, most health care systems have remained in crisis. Throughout economic crises and issues

importing pharmaceutical supplies, governments have chosen to protect personnel numbers at the expense of buying

medicines, or other materials needed to allow staff to do their job. In addition, health care personnel have

traditionally sought supplementary income by means of informal charges for services rendered or medicine.35

Besides these financial and structural barriers, studies of rural West African populations have shown that distance,

income, family size, and education were main factors impacting the use of health services by rural women.36 Income

32 Rajeev Sadanandan, “Government Intervention in Kerala: Who Benefits?,” Economic and Political Weekly Vol.

36, No. 32, (2001): 3071. 33 The Senior Medical Officer at Njala Hospital, a hospital located on a university campus, explained that ninety

percent of the hospital budget goes toward paying staff while the remaining ten percent was supposed to cover all other costs.

Senior Medical Officer (in charge of hospital policy and administration), in discussion with the author, December 3, 2013.

34 Sadanandan, “Government Intervention in Kerala: Who Benefits?,” 3077. 35 Kenneth Leonard and David Leonard, “The Political Economy of Improving Health Care for the Poor in Rural

Africa: Institutional Solutions to the Principal Agent Problem,” The Journal of Development Studies Vol. 40, No. 4, (2004): 57.

36 Daniel Buor, “Determinant of utilization of health services by women in rural and urban areas in Ghana,”

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and distance are extremely important in regard to the lack of affordable, local services available to the rural poor

across Sub-Saharan Africa. Government health care systems in West Africa may in fact be more in the interests of an

elite few than those of the general population.

Methodology:

With the established definitions and expectations of clientelism, principal-agent theory, and selectorate

theory as outlined above, we may move on to analyze which of these theories best explains the trend towards

centralization of government resources. To gather the necessary information to analyze the situation, I conducted

semi-structured, in person interviews in three main cities of Sierra Leone: Freetown, Bo, and Koidu. Interview

questions were open ended and while interviews had a common theme and general series of questions, no formal or

uniform series of questions were asked. Interviews were not recorded with any audio or visual equipment, but I took

thorough notes which I later transcribed. I interviewed twenty-two people in this manner. With two exceptions,

every person I interviewed was either a high ranking employee of the Ministry of Health, a hospital administrator, or

a doctor. I contacted my interviewees by way of snowball sampling. Thus, my sample is not random as it constitutes

a specific group of elite, educated members of Sierra Leonian society. With the information I gathered in these

interviews, I constructed a more complete picture of Sierra Leone's political climate and health care system than was

previously possible.

Case Study: Sierra Leone Governance and Health Care System

Sierra Leone's Background and Political System:

Sierra Leone, a small coastal West African country, is a parliamentary democracy with a

unicameral legislature and directly elected president. Originally British Colony, Sierra Leone is

perhaps best known for its recent decade long civil war, lasting from 1991 to 2002, which

GeoJournal Vol. 61, No. 1, (2004): 89.

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displaced almost a third of the population, destroyed much state capacity, and was known for

excessive brutality. Since then, the government has seen two peaceful presidential elections in

2007 and 2012, electing Ernest Bai Koroma of the All People's Congress as President in both

elections. The country is divided into four administrative regions, further separated into fourteen

districts (see Figure 1).37 Despite this large spread, however, a main feature of Sierra Leone's

political system over time has been the centralization of power and resources in Freetown. In the

last decade there as been a push for some decentralization including the Local Governance Act of

2004, but some speculate that the act was merely a political ploy to obtain more funding from the

World Bank and UNDP.38

As of the Local Governance Act of 2004, each district has a legislator who interacts with

the central government, as well as an elected district council, and several chiefs with whom

traditional authority rests within communities. Two main parties dominate politics in Sierra

Leone: the Sierra Leone People's Party (SLPP), and the All People's Congress (APC). While the

economy is primarily based on mineral exploitation, most of the population relies on agriculture

for a living. The capital of Sierra Leone is Freetown, previously a British settlement for freed or

escaped slaves. The second largest city and urban hub is Bo.39 Sierra Leone is a poor country,

plagued with drastic social inequalities. Because of this, the average life expectancy is very low,

at fifty-five years, almost one fourth of all children in Sierra Leone are malnourished, and the

country has a reputation for the worst place in the world to give birth due to maternal and child 37 "Sierra Leone," The Columbia Encyclopedia, (New York: Columbia University Press, 2013),

https://login.ezproxy.carleton.edu/loginurl=http://search.credoreference.com/content/entry/columency/sierra_leone/0 (accessed March 14, 2014.)

38 Paul Jackson, “Reshuffling an Old Deck of Cards? The Politics of Local Government Reform in Sierra Leone,” African Affairs (2006): 103.

39 "Sierra Leone," The Columbia Encyclopedia, (New York: Columbia University Press, 2013), https://login.ezproxy.carleton.edu/loginurl=http://search.credoreference.com/content/entry/columency/sierra_leone/0 (accessed March 14, 2014.)

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mortality rates.40 While Sierra Leone is a parliamentary democracy modeled after the British

system, electoral politics are unique in the informal authority of local chiefs, and prevalence of

patron-clientelism between voters and political parties.

One element of Sierra Leone's governance structure is that of the chieftaincy. The

chieftaincy includes a council including a paramount chief, sub-chiefs, and “men of note.” An

electoral college of councilors elects chiefs from hereditary families. In addition, paramount

chiefs are also reportedly members of specific Sierra Leonean secret societies. It is believed that

the secret societies rather than the actual chiefdom councils have decided many critical issues.

This reduces government accountability and transparency as well as increasing the power of the

rural elite over the general population.41 These rural elite are elected by twenty taxpayers. The

ambiguous word “taxpayer” has allowed chiefs to control the electoral college and effectively

exclude women and poor people.42 Thus, large groups of people are excluded from the patronage

system and effectively have no hope of advancement in society. This often leads not only to

massive mismanagement of resources and abuses of power, but also a failure to deliver public

services.43 Across Sierra Leone, there are one hundred and forty nine chiefdoms. Relying on a

social contract between the chief and his constituents, the chief embodies a mix of traditional and

bureaucratic power. With acts dating far back through colonial rule,44 the chiefs’ powers are

40 “Sierra Leone,” Health Poverty Action, last accessed February 10, 2014,

http://www.healthpovertyaction.org/where-we-work/africa/sierra-leone/. 41 Jackson, “Reshuffling an Old Deck of Cards? The Politics of Local Government Reform in Sierra Leone,” 105. 42 Jackson, “Reshuffling an Old Deck of Cards? The Politics of Local Government Reform in Sierra Leone,” 96. 43 “Sierra Leone: Strategic options for public sector reform,” World Bank, (Report no. 25110, Washington, DC,

2003). 44 “Colonial rule undermined the institution of chieftaincy by limiting the powers of chiefs and introducing depositions and strengthening the position of individual chiefs by removing the traditional checks and balances

on misuse of power, without putting anything satisfactory in its place.” Cassandra Veney and Dick Simpson, African Democracy and Development: Challenges for Post-Conflict

African Nations, (Maryland: Lexington Books, 2013), 162.

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written into the constitution.45 In rural areas, the chief is often the highest source of government

authority as well as tax collector and judge. With the chief's power to collect taxes, ownership of

all land, and ability to appropriate resources came a tendency for chiefs to use their positions to

enrich themselves at the public’s expense. Despite their reputation for corruption and

mismanagement,46 the chieftaincy is valued as an institution.47 The chieftaincy is a traditional and

relevant institution in Sierra Leonean politics.

The Ministry of Local Government advocates that the chiefs should be loyal to the

government whichever party is in power. However, chiefs are rarely apolitical and most belong to

either the SLPP or the APC. This leads to political patronage in a variety of forms. First of all,

chiefs are often a part of wide patronage networks (such as those extracting diamonds or other

natural resources) orchestrated by political figures at the national level.48 Second, members of

parliament and those of the party in power often rely on chiefs to mobilize voters for political

support. In doing so, chiefs generally rely on political patrons for resources to manage those

networks and reward supporters.49 If a chief's political loyalty is in doubt, it is not uncommon for

members of the central government to threaten them with a corruption probe. In some cases,

chiefs have been reduced to acting as glorified government spokespeople.50 Despite this, rural

45 Jackson, “Reshuffling an Old Deck of Cards? The Politics of Local Government Reform in Sierra Leone,” 96. 46 Many believe that as individuals they lack a voice in the chiefdom and to the government and believe that the

system serves only to benefit an elite few at the expense of the public. 47 Jackson, “Reshuffling an Old Deck of Cards? The Politics of Local Government Reform in Sierra Leone,” 98. 48 Some argue that patrimonial rulers of Sierra Leone have consistently chosen to mobilize citizens and maintain

personal control via private control of informal markets such as diamonds rather than build strong bureaucratic institutions to mobilize citizens.

William Reno, Corruption and State Politics in Sierra Leone, Cambridge: Cambridge University Press, 1995): 177.

49 Jackson, “Reshuffling an Old Deck of Cards? The Politics of Local Government Reform in Sierra Leone,” 99. 50 Hazel McFerson, “Women in post conflict society in Sierra Leone,” Journal of International Women's Studies

Vol. 13, No. 1 (2012): 51.

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citizens trust chiefs over elected chancellors51 as can be seen in voting patterns.

The votes of rural citizens in Sierra Leone are often determined by the chiefs’ wishes for a

variety of reasons. First of all, the chiefs generally have control over all of the land in their area

as well as the activities people engage in. Because of this, people are nervous to go against the

chief as they could take action against citizens who don't obey. Second, people might feel they

owe the chief due to patronage networks and can be manipulated that way. In many cases, voters

feel indebted to the chief due to previous socioeconomic assistance the chief provided. Chiefs

may then call on norms of reciprocity and loyalty to mobilize voters. Third, voting with the chief

may be a calculated decision on the behalf of the voter due to the fact that when local leaders

have good relationships with the people in power (in theory the chief has a direct connection to

the party he wants others to vote for), it is more likely resources and public goods will be directed

to their district or area. Especially in weak states when bureaucratic agencies lack the capacity to

monitor programs, encourage participation, or adequately distribute resources, the needs of the

community are dependent on their local patron's ability to work with members of the central

government.52 Kyle Simmons, who worked on one of District Legislator's campaigns in Kono,

witnessed the patronage network firsthand. While working in swing-district Kono, or the main

diamond-mining district of Sierra Leone, Mr. Simmons observed that the APC gave out monetary

favors in return for voting for them both before and after the election. After the election, since the

majority of people in Kono voted for the APC, the central government authorized the main cities

in the district to get paved roads connecting them to major cities, as well as electricity and street

51 Veney and Simpson, African Democracy and Development: Challenges for Post-Conflict African Nations, 149. 52 Kate Baldwin, “Why Vote with the Chief” Political Connections and Public Goods Provision in Zambia,” (PhD

diss., Columbia University, 2012) 4.

16

lights.53 54 As shown above, voters choose candidates based on their chief's preferences and are

rewarded for voting the “right way” through political patronage.

Political party mobilization and candidate choice is heavily influenced by ethnic identity.

First, chiefs' relationships to candidates are often tribal, especially on a local level. In that regard,

ethnic identity matters much more than economic class, policy, or qualification. Several workers

on district legislature campaigns found this to be true when unqualified, unmotivated people of

the 'right' ethnicity won the seat over more qualified individuals of a different ethnic identity.

Additionally, studies found that across multiple elections, ethnic identity was a major predictor of

political behavior in vote choice.55 Second, the parties themselves are based along ethnic lines.

Both parties have strong ethnic affiliations and deep-seated patronage networks benefiting their

respective elites. The SLPP's base constituency is in the Mende in the Southern and Eastern

provinces while the APC's base is in the Temne and Limba tribes in the Northern Province (see

Figure 2). The party platforms do not differ much in policy or plan, but instead rely on patronage

and ethnic identity to mobilize voters.56 57 Party lines, voter mobilization, and voter preferences

are all contingent on ethnic identity.

Sierra Leone's Health Care System: 53 Kyle Simmons (worked on various campaigns for current Minister of Water), in discussion with author, February

17th, 2014. 54 This phenomenon has also been documented throughout literature including in: Fodei Batty, “Do Ethnic Groups Retain Homogenous Preferences in African Politics? Evidence from Sierra

Leone and Liberia,” African Studies Review Vol. 54, No. 1 (2001): 126. 55 Fodei Batty, “Do Ethnic Groups Retain Homogenous Preferences in African Politics? Evidence from Sierra

Leone and Liberia,” 127. 56 Christopher Wyrod, “Sierra Leone: A Vote for Better Governance,” Journal of Democracy Vol. 19, No. 1,

(2008): 75. 57 One a side note, one study showed that when there are multiple candidates of the same ethnic identity, voter

preferences become much more based on policy and platform. Fodei Batty, “Do Ethnic Groups Retain Homogenous Preferences in African Politics? Evidence from Sierra

Leone and Liberia,” 140.

17

Sierra Leone's health care system is a mix of government, private, and NGO facilities. In

each district there is one major government hospital and at least one peripheral health unit (PHU)

per chiefdom. While government hospitals attempt to handle all maladies, PHUs mostly focus on

maternal care and attending to births, as well as malaria treatment. Within chiefdoms, there are

also maternal and child health clinics for each population of 200-250 people and community

health posts for populations of over 250 people. The clinics and health posts are manned by

community health officers and maternal and child health attendants. All of these places refer

patients to the main district hospital.58 In the district hospitals the government provides all staff

with the exception of teams from other countries. Staff and medicine are allocated based on the

target population (to be treated). District populations are collected by census, and the

“cachement” population is determined by the individual centers.59 Besides the main government

health care, in 2010 President Koroma launched “Free Health Care Medical Insurance (FHC)”,

providing free health care to pregnant and lactating women, as well as children under the age of

five. Funded mainly by the United Nations and the United Kingdom, the FHC provides a variety

of basic medicines for mothers and children and pays for a salary increase for all doctors.60 61

This program was intended to combat Sierra Leone's former title of the country with the highest

maternal and child mortality rate. Most women and children were not accessing health services,

58 Dr. Levy, (head doctor at Koidu hospital, the district hospital for Kono), in discussion with author, December 13,

2013. 59 Foday Sawi (Deputy Minister of Health), in discussion with author, December 6, 2013. 60 “Sierra Leone: 1st Anniversary of the Free Health Care System,” Oxfam International, accessed February 10,

2014, http://www.oxfam.org/en/campaigns/health-education/sierra-leone-1st-anniversary-free-healthcare. 61 This trajectory of improving health service delivery through proving basic health services in conjunction with

international donors and NGOs is common for post conflict nations with damaged infrastructure, and limited human resources.

Bayard Roberts, Samantha Guy, Egbert Sondorp, and Louise Lee-Jones, “A Basic Package of Health Services for Post-Conflict Countries: Implications for Sexual and Reproductive Health Services,” Reproductive Health Matters Vol. 16, No. 31 (2008): 57.

18

in large part because they could not afford to. In addition, the services were low in quality and

health centers did not have the medication necessary to treat patients. Instead, the centers were

buying drugs from the markets and selling them for profit to patients. Workers were uneducated

and children and women were dying in mass numbers. All in all, the government saw the figures

as a disgrace and an embarrassment. The Deputy Minister of Health explained that the main goal

of the law was to increase accessibility and quality of care. For improved access, however, the

Deputy Minister advocated that care needs to be free and there needs to be pay increases for staff

members to improve their “motivation”. The law also ensures the most important medicines are

available. The Ministry of Health, rather than the hospitals, decides which medicines are ‘most

important’ and thus provided for free. The Deputy Minister says the law has been successful in

that pregnant women are coming in multiple times during the pregnancy and bringing in their

children when they are sick. While there are still some issues in distribution and drug availability,

the Deputy Minister believes the law is working as it is was intended.62 Journalists and NGOs

have shown, however, that despite the existence of government, private, and NGO-run facilities,

many Sierra Leoneans do not have access to affordable health care due to limited access to

facilities, personnel, and paved roads. Even within healthcare facilities, there is only an average

of three doctors for every 100,000 people.63 Because of this, less than one third of Sierra

Leoneans will see a nurse if they are ill and less than one quarter will see a doctor.64 Additionally,

access to doctors instead of nurses is often dependent on socioeconomic status – those who are 62 Foday Sawi (Deputy Minister of Health), in discussion with author, December 6, 2013. 63 The World Health Organization (WHO) recommends at least 228 doctors per 100,000 people. 64 Interviews with many scholars and citizens of Sierra Leone revealed that even if people could not afford health

care, many borrowed money to go to private hospitals over public ones because in private hospitals there were many more doctors and equipment.

Prof. Skran (head of an NGO in Sierra Leone and Professor of Political Science at Lawrence University) and Mrs. Maligi (the first woman in Sierra Leone to get a foreign college degree), in discussion with author, December 2, 2013.

19

considered poor are much less likely to see a doctor than those with money.65 66 Despite the

existence of many types of healthcare facilities, Sierra Leone's health care system is lacking in

infrastructure and personnel.

In Sierra Leone the Ministry of Health regulates and controls all aspects of the health care

system. First, if doctors choose to work in the public sector, the government chooses where they

are stationed. Because of this, many doctors choose to work in private practice because they can

better control where they work and live. All doctors complete their residency in Freetown, with

one forty day posting in a rural area during their residency. Once they finish this, they return to

Freetown to finish their training. After doctors finish medical school, the Ministry of Health

decides where they will be placed and for what duration.67 68 Some doctors believe the

government interferes too much in staff allocation. For example, one senior doctor advocated that

the government takes nurses away from Freetown before they finished their residency to fill the

needs of rural areas. Local politics then prevent the nurses from returning unless the government

sends out replacement staff, essentially preventing the nurses from completing their training.

Second, the Ministry of Health directly pays the salaries of doctors who work in public hospitals.

Since 2010, all doctors and nurses received a 200-500% salary increase that is supplemented by

funding from the United Nations and the United Kingdom.69 Third, the government supplies all

65 “Individuals who are considered poor see a nurse instead of a doctor (48.6 compared to 9.3%), whereas the non-

poor see a doctor (32.5 compared to 26%).” Fredlanna M'Cormack, Fredline M'Cormack, and John Yannessa, “Lactating Women's Perception of the Free

Health Care Initiative in Rural Sierra Leone,” World Medical and Health Policy Vol. 4, No. 1, Article 5 (2012): 3. 66 M'Cormack, M'Cormack, and Yannessa, “Lactating Women's Perception of the Free Health Care Initiative in

Rural Sierra Leone,” 3. 67 Medical Students at Connaught Hospital, Sierra Leone, in discussion with author, December 9, 2013. 68 Dr. Young (head doctor at Bo district hospital), in discussion with author, December 14, 2013. 69 The Ministry of Health hoped that this increase would both reduce the incidence of doctors extracting extra

money from patients as well as prevent many qualified doctors from leaving the country in order to obtain better pay.

Dr. Rogers (surgeon at Connaught Hospital, Freetown), in discussion with author, December 6, 2013.

20

medicine to the hospitals. This, in theory, makes it more cost effective for patients to buy

medicine from the hospital than it does to buy medicine in the market or at a private hospital or

pharmacy.70 Fourth, the ministry provides hospitals with all equipment and tools. Across all

interviews with doctors, hospital administrators, and nurses, the consensus was that the system

the government uses is not conducive to good work. The government operates on a “push

system” rather than a “pull system.”71 That is, the government buys hospital equipment such as x-

ray machines, needles, operating room tools, refrigerators, etc., and gives the equipment to

hospitals at their discretion. The Deputy Minister of Health explained that when the hospital has

extra equipment, it attempts to distribute it in the fairest way possible. Claiming the distribution

to be need based, the deputy minister explained that if they had an x-ray machine to give, they

would put it in a place with no x-ray machine rather than in one with a semi-working, old, or

damaged x-ray machine. If they instead had testing facilities for tuberculosis, the government

would send them to a place with the highest rates of tuberculosis.72 Under the current system, the

Ministry theoretically provides main hospitals with a quarterly restocking of tools including

stationery, printers, ambulance maintenance, motorbikes, operating theatre equipment, and other

administrative infrastructure.73 Many doctors reported that the push system often prevents them

from being able to do their jobs in a satisfactory way. From having the correct sutures for

surgery, to the correct form of antibiotics to save a child, or even just having a chest tube for

emergencies, many doctors lack the basic tools they need to treat patients.74 75 In contrast, the

70 Dr. Rogers (surgeon at Connaught Hospital, Freetown), in discussion with author, December 6, 2013. 71 Foday Sawi (Deputy Minister of Health), in discussion with author, December 6, 2013. 72 Foday Sawi (Deputy Minister of Health), in discussion with author, December 6, 2013. 73 Hospital Administrator (Koidu Hospital), in discussion with author, December 13, 2013. 74 Dr. Young (head of the doctors at Bo Government Hospital, in discussion with author, December 14, 2013. Foreign doctor working contract at Princess Christian Maternity Hospital in Freetown, in discussion with author,

December 10, 2013.

21

pull system would involve hospitals outlining their needs and the government responding to those

specific requests. In any case, the government provides all services to government hospitals.

Despite the fact that the government works on a push versus a pull system, the Ministry

accepts reports and requests from hospitals and attempts to fill their needs. Most administrators

cited that the most common requests they send to the ministry were for medicines, equipment,

and staff. All hospitals cited that they would frequently run out of medications, but both hospitals

and Freetown and the government hospital in Bo reported that shortages did not last for long and

that the government restocked hospitals frequently. The Secretary Administrator at the Bo

government hospital said that if they run out of medicines or tools, the government restocks the

hospital usually within one week. For less critical stocks of medicines, the pharmacy submits

reports of what it wants months ahead of time, and generally receives their order within two

weeks.76 Reporting also allows the Ministry to keep track of what the most popular medicines

are, what is most needed in hospitals, and patterns of staff movement and work. A Matron, or

head of the nurses, at a hospital in Freetown advocated that in her reports she submitted to the

Ministry of Health, she included information on how the nurses work, their punctuality, hours

worked, presence of transfers, working habits, and more in addition to requests for more staff.77

In addition, people from the Ministry of Health reportedly come often to monitor progress,

Dr. Rogers (surgeon at Connaught Government Hospital in Freetown, in discussion with author, December 6,

2013. 75 Most news sources report frequent incidences of medicines not being delivered to facilities or in general not

reaching patients at all. Some researchers report that part of the availability problem lies with the theft and re-sale of drugs at high levels, including among government staff

M'Cormack, M'Cormack, and Yannessa, “Lactating Women's Perception of the Free Health Care Initiative in Rural Sierra Leone,” 11.

76 Matron at King Harmon Hospital in Freetown, in discussion with author, December 6, 2013. Medical students at Connaught Hospital in Freetown, in discussion with author, December 9, 2013. Komba A. Momoh (Secretary administrator at Bo Government Hospital), in discussion with author, December

14, 2013. 77 Matron at King Harmon Hospital in Freetown, in discussion with author, December 6, 2013.

22

observe doctors, and collect their own numbers on the number of patients seen, medicines used,

and more.78 The Ministry of Health then works as its own regulatory agency – tracking what is

happening with the supplies and staff it provides and deciding what policies to pursue in future.

While the Ministry enacts the same policies in all government hospitals, hospitals in

Freetown receive preferential treatment in staff allocation, equipment supply, and financial aid.

Doctors in Connaught hospital, the main government hospital in Freetown, as well as doctors and

administrators in Bo and Koidu agree that hospitals in Freetown receive more resources and staff.

Because, in many cases, the only equipment is in Freetown, patients come in from all over the

country to Freetown to be treated (for example, the only functioning x-ray machines are in

Freetown).79 In addition, some advocate that the staff in Freetown are better qualified than in

other areas of the country.80 While most main government hospitals in districts will have one to

three doctors, there are over twenty doctors in Connaught alone (and there are at least three main

government hospitals in Freetown, not to mention NGO run and private hospitals) with a rotating

thirty to forty doctors who come in to teach every year.81 82 Besides Sierra Leonean doctors,

hospitals in Freetown also enjoy the advantage of visiting teams of doctors from other countries.

For example, a team of Chinese doctors, heading each department, staffs King Harmon Hospital

78 Medical students at Connaught Hospital in Freetown, in discussion with author, December 9, 2013. Dr. Young (head doctor at Bo district hospital), in discussion with author, December 14, 2013. 79 Many people die because of this lack of accessibility. In many rural areas for example, there is only

transportation to Freetown once a week. In addition, once patients reach Freetown, they cannot afford housing or transportation back to their districts. People then are unwilling to leave the hospital and there is a large problem trying to supply beds.

80 Dr. Murray (Director of Outpatients at Connaught Hospital), in discussion with author, December 5, 2013. 81 Dr. Rogers (surgeon at Connaught Government Hospital in Freetown, in discussion with author, December 6,

2013. 82 Likewise, in Bo they now have over two hundred nurses in the government hospital to cope with the influx of

patients from the Free Health Care Initiative. The nurses were sent there under orders from the Ministry as Bo is the second largest city in Sierra Leone.

Komba A. Momoh (Secretary administrator at Bo Government Hospital), in discussion with author, December 14, 2013.

23

in Freetown. This particular team also brought their own equipment and medicines, giving an

estimated 70% of them to the hospital.83 The Ministry of Health is sensitive to the needs of

hospitals in Freetown.

The Ministry of Health is not as responsive to the needs of other district hospitals across

Sierra Leone. For example, the government hospital in Koidu serves all of Kono district, yet it

lacks the basic services required to treat patients. In Kono, there are three total doctors for a

population of approximately 352,000 people. One doctor in Koidu said that his salary was “not

enough to live”, and that he would be much better off financially in Freetown as there was more

work to do (and thus higher pay for him). Because of this, the doctor argued that most people that

were posted in rural areas go back to Freetown for better work opportunity and pay.84 They have

not received any extra staff to treat the influx of patients from the FCH, and the hospital lacks

basic elements including an enclosure or building within which to treat pregnant mothers

(currently a small shack without walls), suture materials for surgery, or blood pressure readers. In

addition, there is no working electricity at the hospital, ensuring that the hospital cannot do

certain tests (the hospital also often lacks slides for the microscope) and that for any serious

maladies like advanced malaria or tuberculosis, doctors have no choice but to send their patients

to Freetown. Additionally, at the time of interview in late December, the hospital had only gotten

the promised government resources for quarters one and two out of four for the year. Further

weakening the hospitals ability to function, the government cut the hospital's resources and

budget for the year 2013. According to the hospital administrator, the government is often

83 Matron at King Harmon Hospital in Freetown, in discussion with author, December 6, 2013. 84 Doctors are paid a base salary but essentially receive commission on surgeries they perform. Dr. Levy (one of two doctors stationed at Koidu Government Hospital), in discussion with author, December 13,

2013.

24

unwilling to restock the medicines and instead accuses the hospital of stealing the medicines or

selling them illegally. The hospital administrator stated that the hospital went into severe debt

this year attempting to buy the medicines and equipment they needed privately. Reasons for

delays in refueling may not be entirely personal, however. The dirt road from Freetown is not

very smooth and often during the rainy season, Kono is completely cut off due to the lack of

pavement and infrastructure. While ministry agents occasionally come to Koidu, they generally

only collect information on the amount of FHC medicines used and the costs of medicines.85 The

FHC medicines are restocked much more frequently than medication and equipment for the

general public, almost monthly, perhaps because of the involvement of the United Kingdom and

UNICEF. This unfortunately is no phenomenon.

Surveys of public resource delivery have shown that resources given to provincial offices

were minimal when compared to the resources allocated to Freetown. For example, a 2003 study

showed that schools “received only 45% of government-fee subsidies, and medical officers

received less than 10 percent of essential drugs sent to them.”86 While the government hospital in

Kono district submits reports and ministry agents somewhat monitor their activity, the Ministry

of Health does not respond to their needs in the same way they do Freetown and Bo hospitals.

There has been much speculation towards why resources are so centralized in Freetown, Sierra

Leone. To many administrators, the answer was obvious. The secretary administrator in Bo

nonchalantly quipped, “Of course [Freetown gets more resources] – they are closer to the

authorities”. With a personal relationship to the people he reports to within the ministry, he can

more easily ask for what resources he needs and extends the idea that administrators in Freetown

85 Hospital Administrator (Koidu Hospital), in discussion with author, December 13, 2013. 86 Marda Mustapa and Joseph Bangura, Sierra Leone Beyond the Lome Peace Accord (New York: Palgrave

MacMillan, 2010), 123.

25

have even better access to the bureaucrats who can supply what the hospital needs.87 Solidifying

a personal relationship, hospital administrators are chosen by the Ministry of Health each time a

new party is in power. This choice is reportedly not based so much on qualification as it is on

party loyalty.88 Thus, for at least the administrators at the major hospitals in Freetown and Bo,

hospital administrators presumably have working, ongoing relationships with those who hold

decision-making power in the Ministry. When asked about the centralization of resources, the

Deputy Minister of Health replied, “we see [Freetown's] problems every day. They are in our

face”. Continuing on to add an anecdote about how he visited a rural hospital and saw their

problems once, The Deputy Minister depicted the centralization of resources as a natural outcome

of the current system. Citing that foreigners and the government elite were most likely to reside

in Freetown at all times, the minister made it clear that the appearance of the health care system

and elite access to it were determining factors in where the Ministry distributed resources.89 90

The location of those in power, as well as their relationships with hospital staff may be a strong

deciding factor in the allocation of resources in Sierra Leone.

One main problem hindering inclusive and efficient service delivery is that the present

institutional arrangement for the distribution and maintenance of health care attributes policy

management, finance, and actual service provision to one government agency: the Ministry of

Health. Given that there is no competition and little specialization, government health units can

87 Komba A. Momoh (Secretary administrator at Bo Government Hospital), in discussion with author, December

14, 2013. 88 Medical Students at Connaught Hospital, Sierra Leone, in discussion with author, December 9, 2013. 89 Foday Sawi (Deputy Minister of Health), in discussion with author, December 6, 2013. 90 It is debatable, however, that elite people are even treated in Sierra Leone. Doctors in Connaught hospital, the

main government hospital in Freetown, advocated that if one applied to the government for treatment overseas and had a strong enough political connection, the government would fund 100% of the treatment and travel costs.

Dr. Rogers (surgeon at Connaught Government Hospital in Freetown, in discussion with author, December 6, 2013.

26

get away with being run as if they were private entities. Misappropriating funding and falsely

retaining fees becomes an easily accessible form of corruption disguised as allocation of public

goods.91 In addition, stories of medicine shortages and problems with the health system can be

challenged more easily as the only people collecting data are the same people on whom the data

reflects.92 Deficiencies in monitoring and accountability allow mismanagement and corruption to

go unchallenged and have provided ample opportunities for elite to benefit at the public's

expense. One of the main shortcomings of this system occurs because there is no monitoring of

agency activity outside of the agency itself, there is no real way to institute reform, and no outlet

for the population to complain. A twenty-three year old woman told Amnesty International, “My

baby was crying a lot and had a fever. Hospital had no drugs for him. Need to pay money. They

chased me away. I don’t know how to complain.”93 Considering that fire-alarm signals are the

main way legislators can keep track of bureaucratic activity, the lack of monitoring and

regulatory agencies effectively suppresses the population and ensures that their voices are not

heard. Combining management, financing, and policy choice into one agency excludes non-elite

such as the rural poor from accessing services and demanding change.

Implications and Options toward Improved Public Service Delivery

Sierra Leone is inherently clientelistic in its voting patterns. Many authors have defined clientelism as a

91 Mustapa and Bangura, Sierra Leone Beyond the Lome Peace Accord, 123. 92 Ibrahim Jaffa Condeh, “Sierra Leone: Pujehun Women Unhappy with Free Health Care Delivery,” Concord

Times (Freetown), 10 October 2013, accessed November 15, 2013, http://allafrica.com/stories/201310101536.html.

93 “Sierra Leone: Pregnant women still denied lifesaving medical care,” Amnesty International, September 6, 2011, accessed January 8, 2014, http://www.amnesty.org/en/news-and-updates/report/sierra-leone-pregnant-women-still-denied-lifesaving-medical-care-2011-09-05.

27

system of governance in which material goods are exchanged for political support.94 As has been shown above, the

patronage-based relationship between political elite and chiefs in return for voter mobilization95 has allowed elite to

control the vote without serving the larger population. Because people have incentive and in the past have

traditionally voted with their chief, or the highest source of local authority, elites have only had to appease chiefs in

order to win votes. While part of this relationship is ethnic based and party lines are largely drawn by ethnic

identity,96 97 convincing and placating the chiefs ensures votes.98 As explained in the case study above, political elite

rely on chiefs to mobilize voters in return for political patronage, making Sierra Leone's politics inherently

clientelistic.

Clientelism, by definition, leads to a pilfering or neglect of public goods to allow for the distribution of

private favors. Thus, by the nature of the system, public health care naturally loses funding and political priority as

elites use the resources available to them to instead maintain the patronage networks that keep themselves in

power.99 Due in part to unchecked executive powers100 and other features of Sierra Leone's political system,

clientelism is not surprising. The lack of resources devoted to health care, to be expected using predictions of

clientelistic behavior in society, is merely a symptom of the political climate. However, lack of resources does not

explain the centralization of health care goods in the capital city of Freetown.

The centralization of Sierra Leone's health care system can be instead described by principal-agent theory.

Applying agency theory to the case at hand, the public, or in this case the principal, contracted the ministry of health,

94 Brinkerhoff and Goldsmith, “Clientelism, Patrimonialism, and Democratic Governance: An Overview and

Framework for Assessment and Programming,” 40.

95 Baldwin, “Why Vote with the Chief” Political Connections and Public Goods Provision in Zambia,” 4. Kyle Simmons (worked on various campaigns for current Minister of Water), in discussion with author, February

17th, 2014. 96 Batty, “Do Ethnic Groups Retain Homogenous Preferences in African Politics? Evidence from Sierra Leone and

Liberia,” 127.

97 Wyrod, “Sierra Leone: A Vote for Better Governance,” 75. 98 Reno, Corruption and State Politics in Sierra Leone, Cambridge: Cambridge University Press, 1995): 177. Jackson, “Reshuffling an Old Deck of Cards? The Politics of Local Government Reform in Sierra Leone,” 99. 99 “Political Clientelism, Social Policy, and the Quality of Democracy: Evidence from Latin America,” 5.

van de Walle, “Presidentialism and Clientelism in Africa’s emerging party systems,” 310.

100 van de Walle, “Presidentialism and Clientelism in Africa’s emerging party systems,” 312. Landman and Larizza, “Inequality and Human Rights: Who Controls What, When, and How,” 719.

28

the agent, to maintain an adequate health care system across the country when they voted the current party into

power. In addition to providing the services themselves, the ministry serves as its own regulatory agency and

management. All hospitals report to the ministry in addition to the ministry collecting its own evidence: sending

teams of doctors to hospitals to monitor how many patients are seen, doctor performance, medicines used, medicine

cost, and more.101 Transferring all power to the Ministry of Health was necessary as the general public lacks the

knowledge, funds, and access to build their own health care system, provide the necessary equipment,102 and monitor

its actions. Thus, they must rely on the ministry to do the job for them. The health care system can be explained by a

principal-agent relationship.

Sierra Leone's health care system suffers from the principal agent problem of moral hazard. Moral hazard as

described by the Encyclopedia of Power is a facet of a relationship in which, “Agents and principals often have

competing self-interests, despite the fact that the agent is hired specifically to represent the interests of the principal.

The [agent] could put his or her interests ahead of the [principal's] by taking payment and not putting forth a strong

effort.”103 In other words, the interests of the agent may conflict and take away from the interests of the principal.

Testimonies, inspections, and mapping have shown that health care resources are highly centralized in the capital

city, Freetown. While there has been much speculation and a multitude of reasons as to why this is, personal

testimony from the Minister of Health revealed that because the ministers and political elite reside in Freetown along

with foreign tourists and diplomats, and because the health care problems of Freetown were more accessible and

visible to the elite, the Ministry of Health actively places most of their available resources into hospitals in Freetown.

Thus, as the government has incentive to improve its public image by improving the health care system seen by

foreigners, solve the problems assaulting them every day by nature of their residence, and improve the health care

available to other government members, wealthy people, and elite living in Freetown, the Ministry's interests in

centralizing health care do not coincide with the interests of the rural public. This may be accentuated by the fact that

residents of Freetown, including dissatisfied citizens and hospital administrators, may have more avenues to

101 Dr. Young (head of the doctors at Bo Government Hospital, in discussion with author, December 14, 2013. Medical Students at Connaught Hospital, Sierra Leone, in discussion with author, December 9, 2013. 102 Medicine and equipment must be imported from other countries into Freetown, giving the government almost

exclusive access. 103 Quinn, "Principal-agent Theory."

29

complain to government and raise “fire-alarm” signals. One thing potentially causing the divergence in funds based

on conflicting interests may be citizen access to government.

Fire-Alarm oversight involves the agent in question learning from and responding to external reporting of

disasters, complaints, and dissatisfaction. This is, of course, assuming that the principal has access to these reports

and the ability to employ budgetary or legislative controls over the agent.104 Sierra Leone's health care system suffers

from the fact that it lacks ways in which the public can express their dissatisfaction, as well as ways in which the

public can punish the ministry for acting against their interests. Both of these factors make fire-alarm oversight

impossible, taking all regulatory power away from the public. First, non-elite, especially those who are uneducated,

rural, and poor do not have avenues through which they can complain privately, much less publicly. While chiefs,

the traditional local authority figure, are theoretically a vehicle through which citizens could contact the central

government, colonial legislation has essentially taken away any power chiefs had within the government while

maintaining their power over the community. That, combined with the fact that chiefs are often a part of the main

political party's patronage network, ensures that rural poor do not have adequate means to express dissatisfaction

with the government. Second, the public has no way of knowing what the government is doing. As the Ministry of

Health is its own regulatory agency, what becomes public knowledge is entirely up to their discretion – allowing

them to hide any behaviors the public would not approve of. Third, as the public's only means of punishing the

ministry would be to vote the current party out of power, which would not necessarily gain them better access, the

Ministry of Health has no incentive to serve the interests of the public at large. Without adequate incentives for the

agent to conform to the principal's wishes and lack of fire-alarm oversight, agent decision-making power is

equivalent to abdication of the public's rights in this case.

In order to help alleviate this problem, there are a few systemic changes that can be made to help control the

principal agent relationship such that the interests of the agent are better represented. First, if the Ministry of Health

had a governing body or regulatory agency that had budgetary leverage, for example, then the Ministry would be

held more accountable for their decisions and actions. Second, if the Ministry’s current duties of regulation, service

provision, and management were delegated to multiple agencies, perhaps there would be more accountability,

reporting, and less opportunity for the centralization of resources. Third, if there were a formal outlet for the public

104 Gary Miller, “The Political Evolution of Principal-Agent Models,” 210.

30

to file public complains about their health care system and a public record of these complaints, there would be the

making of fire-alarm oversight. Fourth, to ensure that the public's opinion mattered and that public goods were

valued and better distributed, it would be best if the chieftaincy system were altered such that chiefs did not control

the votes of rural communities. While this option is not realistic or plausible in any foreseeable future, literature has

predicted time and time again that truly engaging the public in voting would lead to an increase in public service

provision. There are many changes to Sierra Leone's political and bureaucratic system that could be made to ensure

increased and more evenly distributed public service delivery.

Conclusion

Battling a continuous lack of financial and human resources, health care in Sierra Leone is not as

comprehensive as political elite and average citizen alike would prefer. With a patronage based, clientelistic political

system, Sierra Leone’s political power is focused in the executive and relies on top-down patronage networks to

maintain power and foster political support. Symptomatic of this system, resources that should be used for the

provision of public goods are often diverted to private hands. However, while this paper shows that Sierra Leone is

clientelistic, the main reason Sierra Leone’s health care resources are diverted to the capital is a problem inherent in

the public-government principal-agent relationship. The principal, the public, relies on the Ministry of Health, the

agent, to evenly distribute and organize health care across the country. However, as the public, especially outside of

Freetown, has no way of influencing Ministry behavior, the Ministry of Health’s interests override those of the

public and the Ministry can consciously concentrate its resources in Freetown for their own benefit. The health care

system in Sierra Leone suffers from a problem in the principal-agent relationship.

There are several forces at work in Sierra Leone’s health care and political system. As such, this piece of

scholarship could benefit from the consideration of more theories regarding how leaders interact with their

constituencies. Additionally, a quantitative mapping of doctor’s movement and placement throughout the country, as

well as any concrete information regarding the timing and quantity of resources sent to hospitals would help to

31

solidify this understanding of the trend toward centralization. Ultimately, any extraneous information detailing the

motives of elite and problems faced during health care implementation would benefit this analysis.

Many developing nations face similar issues while trying to implement a national health care system. As

has been discussed in this paper, while government intervention in health care services ideally corrects for class

inequalities in the private sector, government control of health care often leads to a few political elite making

decisions to benefit themselves at the expense of the community. Hopefully this paper can help explain why public

goods are often centralized in the largest cities of developing nations, as well as illuminate conditions under which

the provision of public goods could increase and be more evenly distributed.

32

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Appendix:

Figure 1: Map of Sierra Leone with district capitals.

105

105 “Sierra Leone,” Central Intelligence Agency World Factbook, accessed April 24, 2014,

https://www.cia.gov/library/publications/the-world-factbook/geos/sl.html.

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Figure 2: Map of Sierra Leone’s tribal territories.

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106 “Sierra Leone – Ethnic Groups,” University of Texas Perry-Castañeda Library

Map Collection, accessed April 24, 2014, http://www.lib.utexas.edu/maps/sierra_leone.html.