When free healthcare is not free. Corruption and mistrust in Sierra Leone's primary healthcare system immediately prior to the Ebola outbreak

INTRODUCTION: Sierra Leone is one of three countries recently affected by Ebola. In debates surrounding the circumstances that contributed to the initial failure to contain the outbreak, the word 'trust' is often used: In December 2014, WHO director Margret Chan used 'lack of trust in governments'; The Lancet's Editor-in-Chief, wrote how Ebola has exposed the '… breakdown of trust between communities and their governments.' This article explores the lack of trust in public healthcare providers in Sierra Leone, predating the Ebola outbreak, apparently linked to widespread petty corruption in primary healthcare facilities. It compares four NGO-supported accountability interventions targeting Sierra Leone's primary health sector. METHODS: Field research was conducted in Kailahun, Kono and Tonkolili Districts, based on interviews with health workers and focus group discussions with primary healthcare users. RESULTS: Field research showed that in most clinics, women and children entitled to free care routinely paid for health services. CONCLUSIONS: A lack of accountability in Sierra Leone's health sector appears pervasive at all levels. Petty corruption is rife. Understaffing leads to charging for free care in order to pay clinic-based 'volunteers' who function as vaccinators, health workers and birth attendants. Accountability interventions were found to have little impact on healthworker (mis)behaviour.