Freetown — There is a brief bustle and then a woman wails as the small body is wrapped in cloth and set on a cot by the door of the paediatric ward.
Nurses in pristine white uniforms continue to pad quietly around the large room at Ola During Children's Hospital in Freetown, Sierra Leone's capital city.
Infants are crammed two or three to a bed, sometimes more. Since the introduction nearly 14 months ago of free health care for pregnant women, lactating mothers and children under five, the number of people coming to seek treatment has shot up. Staffing and equipment has not risen to match, leaving health workers struggling to deal with the influx.
Sierra Leone's ambitious plan to tackle one of the world's highest rates of maternal mortality and infant death has garnered much praise from both international donors - who fund the majority of the program - and from within the country's own borders.
In a country where one in five children dies before their fifth birthday, and one in eight women dies from complications of pregnancy or childbirth, free health care is seen as a huge step forward - and an enormous challenge.
According to a recent report by Sierra Leone's ministry of health and sanitation, government-run hospitals saw about three times as many children under five - nearly three million - in the first 12 months of the program as in the preceding year. More than 126,000 women gave birth in hospital in the first year of the program, compared to about 87,000 in the previous year. The number of maternal complications treated in hospital increased from about 8,000 to over 20,000.
"Although the number of health staff has been increased since the launch of (free health care) it is still insufficient to match the service delivery demand," said the report, entitled "The Free Health Care Initiative: 1 Year On."
At Freetown's largest public hospital for women and children, Dr. Mahmoud Idriss Kamara says the pressure on staff posed by the patient increase is wearing everyone down. Kamara sits behind a battered table, answering questions in between instructing staff, shuffling files, answering phones and signing the death papers for the child who'd just died. He has more than 24 hours left in his shift before he'd be able to get some sleep.
Across the ward, nurse Lucy Macauley says staff exhaustion leads to a poor standard of care for patients. She says they need help and the increase in workload should be accompanied by pay raises. "We're working harder, but for the same pay," says Macauley. Much of the equipment is obsolete and there are chronic shortages of supplies, she says, and the complex, which houses a maternity hospital and a children's hospital, has an inadequate water supply - often, there simply isn't any.
The hospital has been under scrutiny since an incident earlier this year when a woman died there from severe complications while the doctors scheduled to be on duty were absent. Those doctors have since been suspended.
The cost of the first year of free health care is estimated at 36 million dollars, the majority of which is put up by donors. But reports of corruption within the system are widespread. Patients recount being asked to pay for services and medications that should be free, or having to buy drugs when hospital supplies are said to have run out.
Umu Fofanah says she went for an ultrasound during her pregnancy because her doctor was concerned about the position of the baby. "When I went to do the scan, I was asked to pay 35,000 leones," says Fofanah. "Not only me, but about 10 of us who were present."
Other expecting mothers paid the roughly eight dollars for a scan that should have been free, says Fofanah. "But I had no money to pay, so I was sent home."
Fofanah told a friend who happened to be the wife of Amnesty International's Sierra Leone country director, Brima Sheriff. When he learned what had happened, he sent monitors with her to subsequent appointments or accompanied her himself to ensure she received free treatment.
"People are still paying for a lot of drugs and a lot of services," says Sheriff. "This is not a secret. Everyone knows that people are still being asked for money, and it's going into the private pockets of someone, at the expense of the women. The free health care was supposed to be for women but cost is still stopping them."
Jonathan Abass Kamara, the public relations officer for the ministry of health and sanitation, says the government is always ready to react to reports of "the contravention of the principles of free health care." Kamara cited several examples of medical staff being disciplined for extortion of patients or otherwise breaking the rules.
He says the initiative's aim of reducing maternal mortality and infant death has been achieved, though exact figures are not yet available.
A 2009 Amnesty International report identified cost as the largest barrier to women and children accessing health services. In a country recovering from a decade-long war that ended in 2002, 70 percent of the population lives on less than one dollar a day. There are fewer than 100 doctors for some six million people and most health facilities are poorly equipped and lack basics like water supply and electricity.
While calling for better monitoring and accountability measures, Sheriff applauds the initiative and points out that there are a lot of positives to the free health care system. "But we need to recognise that it needs to be improved. We need to ensure that gaps are not left that allow some to defraud others."