Socioeconomic Inequalities in Care-Seeking for Children Under Five Before and After the Free Healthcare Initiative in Sierra Leone: An Analysis of Population-Based Survey Data

Background: There are real socioeconomic inequalities between and within countries, leading to disparities in the use of health services. In children under five years of age, this could be responsible for child mortality by depriving children of healthcare. By removing healthcare fees, the Free Healthcare Initiative (FHCI) adopted in Sierra Leone can contribute to reducing these inequities in healthcare-seeking for children. This study aimed to assess the socioeconomic inequalities in healthcare-seeking for children under five years of age before and after the implementation of the FHCI.Methods: We included 1207, 2815, and 1633 children under five years of age with fever from the 2008, 2013, and 2016 nationwide surveys database, respectively. Concentration curves were drawn for the period before (2008) and after (2013 and 2016) the implementation of the FHCI to assess socioeconomic inequalities in healthcare-seeking. Finally, concentration indices were calculated to understand the magnitude of these socioeconomic inequalities.Results: We found that before the implementation of the FHCI, there were inequalities in care-seeking for children under five (concentration index (CIn) = 0.168, standard error (SE) = 0.049) in favor of the wealthy households. These inequalities decreased after the implementation of the FHCI but remained in favor of the rich households (CIn = 0.039, SE = 0.040). There were more disparities in the healthcare-seeking between districts before the implementation of the FHCI. After the initiation of the FHCI, these disparities were reduced, and 12 of the 14 districts had a CIn around the value of equality. Conclusion: Our study observed pro-rich inequalities in care-seeking for children under five years of age before the implementation of the FHCI and a decrease in these inequalities after its implementation, even if it remained pro-rich. To continue to reduce wealth-related inequalities, policy actions can focus on the increase of availability of health services in the districts where the care-seeking was pro-rich.