Sierra Leone is almost at the bottom in the Human Development Index, ranking 180th out of 187 countries. There is significant gender inequality where a mere 23% of women are literate, half the rate among men, while domestic violence is widespread. In addition, infectious diseases such as malaria, TB and HIV/ AIDS are the leading causes of deaths and illness and, in spite of improvement in women’s and children’s access to services, the under-five mortality rate is the highest in the world. This case study on Sierra Leone is part of the Building Back Better research initiative. The initiative studies four case studies of countries affected by conflict – Mozambique, Timor Leste, Sierra Leone and northern Uganda – to examine whether health system reconstruction has promoted equality and created a health system that is gender equitable.