The Free Health Care Initiative: how has it affected health workers in Sierra Leone

Authors: Sophie Witter, Haja Wurie & Maria Paola Bertone

This 2014 report pulls together findings relating to the Free Health Care Initiative (FHCI), as part of ReBUILD’s wider research on the evolution of incentives for health workers in post-conflict Sierra Leone.

A paper based on findings from this report has been published in Health Policy and Planning.

Background
No study to date has focused on how the decisions made, or not made, in the post-conflict period can affect the longer term pattern of attraction, retention, distribution and performance of health workers, and thus ultimately the performance of the sector. The ReBUILD project, funded by DFID 2011-16, aimed to fill that gap by documenting the evolution of incentives for health workers post-conflict and their effects in four countries. In the case of Sierra Leone, the Free Health Care Initiative (FHCI) emerged as a key catalyst in a series of human resources for health (HRH) reforms. Results relating to the FHCI have been pulled together for this report. The rationale for this is two-fold: first, there is an acknowledged gap in the literature on the impact of fee exemption policies on health staff, and conversely, the implications of staffing for fee exemption. Secondly, an evaluation of the FHCI is underway which can benefit from the analysis carried out by ReBUILD.

Study methods
A retrospective and cross-sectional study utilizing both quantitative and qualitative methods was conducted. Fieldwork was done in 2012-13, collecting data back to 2002, when the conflict ended.

Four districts were chosen to be as study sites – one from each of the regions. They were selected purposively to include rural and urban areas, as well as remote and less remote, poor and less poor areas. The study sites were:

1. Western Area (Urban/Rural)
2. Kenema District (Eastern Region)
3. Bonthe District (Southern Region)
4. Koinadugu District (Northern Region)

Data was collected through the following methods: document review (57 documents – fully reviewed, published and grey); key informant interviews (23 with government, donors, NGO staff and consultants); analysis of human resource data held by the MoHS; in-depth interviews with health workers (23 doctors, nurses, midwives and community health officers); and a health worker survey (312 participants, including all main cadres).

Ethical approval was obtained from the Sierra Leone Scientific and Ethics Committee and the Liverpool School of Tropical Medicine prior to the commencement of the study.

Some study limitations are noted – particularly gaps in the secondary data from the MoHS, as well as more limited insights and documents from the pre-FHCI period. However, there were also strengths – notably, the ability to triangulate between views expressed in official documents with those of key informants (donors, managers etc.) and health staff on the ground. Further, the longer time perspective taken by the study allowed better understanding of the context – the challenges that existed in the health system before the FHCI and those faced now.

Findings

The context pre-FHCI. The post-war context presented familiar features and challenges – particularly, the absence of staff, who had fled, and the proliferation of NGO-supported services, with limited control by the MoHS overall. Gradually, during 2002-9, the MoHS reestablished some leadership, and a series of human resource policy documents and plans were produced. These documents presented the challenges, but did not have much traction in terms of funding and implementation of the measures which they identified as being needed. There were substantial gaps in posts filled and poor working conditions for staff, including low pay and difficulties getting on to payroll.

Launch of FHCI. When the FHCI was launched in November 2009, human resources for health was picked out as an area needing immediate reinforcement as part of the policy’s implementation. In preparation for the FHCI launch, six technical working groups were put in place, one of which focused specifically on HRH issues. These groups held their meetings up to once a week during preparation phase (November 2009 to April 2010). They were tasked with designing the reforms and changes in the health system necessary to ensure the smooth roll out of the FHCI. They also coordinated different partners, assigned roles and identified available funding. Although there were disagreements within the group over priorities and the process was rushed, all sources agreed that the FHCI was the defining moment that shaped the healthcare system and gave a strategic approach to HRH policies.

The main HRH reforms. The logic behind the HRH reforms was that if health care utilisation was to increase then a number of chronic HR problems needed addressing, including:

• Fast-track recruitment and deployment to fill gaps in staffing
• Payroll cleaning to ensure that ‘ghost workers’ were taken off the payroll (and those who were working unpaid – the many ‘volunteers’ – were added)
• Salary uplift to ensure that health workers were adequately paid and motivated to handle increased workload without imposing informal charges on users

These were all introduced early in 2010 to prepare for the launch of the FHCI.

In a second round of HRH reforms (2011-12), a system of monitoring staff absences, linked to a new staff sanction framework, aimed to ensure that the now more generously paid staff were actually at work. The two other main policies introduced during this period were performance based funding to facilities, which could meet the dual needs of providing some small flexible funding at facility level to replace lost user revenues, as well as providing a direct incentive to staff to provide priority services. Finally, a remote allowance was introduced in January 2012 to encourage staff to take up postings in more rural, hard-to serve areas.

Effectiveness of implementation. The report presents details on the rationale, design, implementation and funding of these reforms, all of which were important to ‘protecting the investment’ in FHCI. Broadly speaking, the first wave of reforms and the staff sanction framework were implemented effectively. The fast-track recruitment and deployment filled many gaps in staff, though it was a one-off process. Staff numbers doubled that year, which represents a big increase on previous years’ trends, even allowing for the fact that some of these new recruits were already working but simply not on payroll.

The payroll is now believed to be more robust and producing savings, though it should be noted that more people were added than removed. This is because the issue of people working without being on the payroll was quite severe prior to the FHCI). Salary uplift has contributed to better motivation and retention, especially for higher-level staff. The top grades have seen an increase of more than 700% in their salary. Absenteeism has reduced and people have been sanctioned for non-attendance. However, the later reforms were apparently less effective. Monitoring, feedback and payments under the PBF scheme are erratic and it remains poorly understood, though staff welcome it if it can be strengthened. Of those surveyed by ReBUILD at primary health unit level, a third had received no payment over the previous year, while others had received from one to three payments. For the rural allowances, these are even more erratic and opaque, partly linked to funding problems.

Conditions for success. Presidential support for the FHCI was recognised by all as critical to its success. The fact that donors were able to coordinate to support the FHCI was also of the highest importance. This also brought in a large number of short-term technical assistants, who played a role in enabling quick reforms in time for the launch. All of these factors remain important and are risks in relation to sustainability. For the first three years of funding the salary uplift, for example, DFID paid 22% of the costs and the Global Fund paid 20%. The World Bank is the funder of the PBF scheme.

Views of staff. Staff highlight benefits to themselves, in terms of pay and working conditions, as well as to the health system, in terms of increased use by patients and more investment in the services and facilities. They also highlight the strains, e.g. of managing with too few staff, and perceive some negative effects, such as patients visiting repeatedly to seek free drugs and, for themselves, of having less time to pursue other activities e.g. private business. In the survey, salary is the dominant source of official income for all groups, which may be one of the legacies of the FHCI (other sources are relatively low – the next in overall importance are per diems for training etc.). Only 4% reported any revenues from user fees or any gifts from patients, which suggests that the FHCI is being effectively implemented, though this finding needs cross-checking with patient reports.

Unfinished agenda. Some reforms that are recognised to be important and which were planned for in the NHSSP are still outstanding, perhaps because they require more institutional and deep-rooted reforms. Most sources agree that recruitment and deployment are too centralised and that HR management should be devolved to district level. Within the Ministry, better coordination of HR policies is needed, avoiding ‘silos’ managed by different directorates. The new HSC is yet to be functional, and the performance management contracts are not fully operational. Measures to encourage and retain staff in rural areas require comprehensive packages, including housing and promotion and training opportunities. Revised training and measures focused on boosting quality of care are all part of the unfinished agenda.

There are still too few of some key cadres, such as midwives, and attrition remains high (13% in 2011, across all cadres). Self-reported working hours average 54 hours per week across the staff surveyed by ReBUILD, who report seeing an average of 117 patients per week, which is relatively high. Questions on remuneration reveal substantial differences between doctors and the rest of the staff, with salaries of doctors more than four times that of registered nurses (a differential which increases when other sources are added). This may require attention, particularly given the low number of registered nurses and midwives and their apparently high attrition rate. Known unknowns. There are some areas that will be important to investigate as part of the wider FHCI evaluation. We know that some degree of charging for services continues but we need to understand what the charges are for, how they have changed over time, and why. The authors also failed to find information on the technical quality of care provided by health workers – this will be important to study in relation to the likely effectiveness of the FHCI.

Conclusion. The findings highlight how a flagship policy, combined with high profile support and financial and technical resources, can galvanise systemic changes which were previously not possible. In this regard, the story of Sierra Leone differs from many countries introducing fee exemptions. The impact has been broad and largely positive, in galvanising a series of important health system changes (we focus here on HR as a key pillar) over a period of time. The challenge, as evidenced in Uganda, will be sustaining the momentum and the attention to delivering results as the FHCI ceases to be an initiative and becomes just ‘business as normal’. The health system in Sierra Leone was fragile and conflict-affected prior to the FHCI and still faces significant challenges, both in HRH and more widely.

Read the full report: The Free Health Care Initiative: how has it affected health workers in Sierra Leone