Research for stronger health systems during and after crisis

The development of HRH policy in Sierra Leone, 2002-2012 – report on key informant interviews

Maria Paola Bertone
Sophie Witter

December 2013

Introduction and objectives

The ReBUILD Project 2 in Sierra Leone focuses on Human Resources for Health (HRH), in particular the incentives established for health workers (HWs) and how they have changed since the conflict. The ReBUILD Consortium conducted a document review that helped to identify gaps in available information on HRH policy-making and formulate hypotheses. The key informant interviews detailed in this document aim to build on the document review by filling these gaps with the insights of the actors involved in policy-making in Sierra Leone. The analysis in this report intends to investigate the key informants’ narrative of the sequence of the events, as well as to explore some of the factors that defined the decision-making process in the post-conflict period.

Research methods

23 key informants were interviewed. 12 of the interviewees work or worked at the Ministry of Health and Sanitation (MoHS) or in other governmental agencies. Additionally, 6 NGO representatives, 4 donor representatives and 1 Technical Assistant (TA) were interviewed. Interviews were analyzed using thematic coding. The initial list of themes forms the backbone around which this report is structured. Examining each of the challenges and policy responses in turn, the report is ordered chronologically. Interviews were triangulated with the documentary review. Any similarities and discrepancies were analysed in a reflexive way to understand why the perceptions of the participants differed or otherwise from the reviewed documentation.


HRH context and challenges during and in the aftermath of the crisis

The few interviewees who could recall the period immediately after the conflict described it as challenging for the health system. Most services were completely disrupted and many of the HWs left the country, particularly those in the higher cadres. Other HWs worked for NGOs or held dual positions with NGOs and the MoHS. In this period, a lack of coordination between the different actors of the health system appeared to be an important feature of the policy context. Individual NGOs and donors were acting independently, setting up their own facilities or rehabilitating existing ones, as well as recruiting and remunerating HWs directly.

HRH policies and measures in the immediate post-conflict phase

The reconstruction process started soon after the end of the war (2002) and overall, the MoHS was able to maintain leadership during this period.

Integrating the informal workforce: After signing the peace agreement, it was decided that ‘combat medics’ (i.e., untrained personnel working behind the rebel lines) needed to be reintegrated and retrained as ‘vaccinators’, which proved a useful solution to cope with the lack of personnel for basic services. Similarly, the utilisation of volunteers for primary healthcare services provided some relief to overstretched HWs. Formalising and improving the existing informal workforce was an essential initial step for health systems strengthening in Sierra Leone.

HRH policy-making: 2002-2009: Despite these practical solutions, from 2002-2009 progress in policy-making for the restructure the health workforce was slow. Problems were identified by the MoHS but until 2009, little progress was made. This is likely to be attributable to a lack of clear political vision on the future of the health system. 4 The broader political context also played an important role as the first government elected after the war was weak in terms of leadership and drive for reform. A series of policies were drafted with the involvement of international agencies and external technical assistance. Rather than become effective strategies to be implemented at peripheral level, they stayed ‘on paper’. The consequence was a relatively static approach, which left little room for innovation and focused mostly on policy ‘fire-fighting’.

Introduction of the Free Health Care Initiative and related HRH reforms: 2009-2010

A major event that respondents consistently mentioned in their narratives was the introduction of the Free Health Care Initiative (FHCI) in early 2010. The preparation and launch of the FHCI appears to be the defining moment that shaped the healthcare system and gave a strategic approach to HRH policies.

Drivers of change for the introduction of the FHCI: Most of the respondents recognised the key role of the President as a driver of this reform. Other respondents highlighted the very high maternal mortality rates in Sierra Leone and the financial barriers to access to services. The international context and the popularity of this reform among donors was also mentioned as an important factor.

Consequences of the launch of FHCI: While the impact of the FHCI on the health of the population is under evaluation, it is clear that the launch of the policy had important effects on the health system and its organisation. Above all, the FHCI provided the opportunity to address the issues that previously were partially solved with piecemeal reforms and to strengthen the health system as a whole. It was also an occasion to improve coordination among actors. The announcement of the FHCI created a momentum for collective action and renewed partnership between the different stakeholders in the health sector. However, beyond the FHCI preparatory period, this collaboration between the MoHS and partners seemed to diminish.

HRH changes introduced in preparation for the FHCI

Policy objectives and approaches: The introduction of the FHCI played an instrumental role in pushing new policies and reforms to address HRH issues. HW salaries were increased to be representative of their increased workload and the fact that they could no longer charge informal fees. The need for ‘payroll cleaning’ was recognised by both MoHS and development partners as it ensured that the HWs being paid really existed. Donors wanted to eliminate ‘ghost workers’ and free financial resources, as well as protect their investment and minimize fiduciary risk. The ‘Sanctions Framework’ to reduce HWs absenteeism was also introduced in January 2011. Finally, in order to increase the number of HWs in the short-term, a temporary mobile recruitment programme was introduced at district level.

Issues and challenges in the decision-making process: The decision-making process that led to the selection, design and implementation of these reforms was less smooth than it would appear from the end result. The following issues emerged during the interviews:

(i) The sense of urgency and rush to prepare the reform. This did not allow time to thoroughly analyse problems and potential solutions, which led to frustration for some actors;

(ii) The Technical Assistants (TA) that were involved in the process. The lack of coordination between the large number of external consultants led to incoherence in the decision-making processes. It also resulted in duplication of work and a loss of institutional memory;

(iii) Conflicting donors’ agendas, in particular around the merits of a salary increase compared to a performance-based financing (PBF) scheme. Moreover, the MoHS seemed to be caught in the cross-fire between donors, resulting in fragmented policies and strategies. In addition, focus was given to the immediate design of the policies rather than the implementation, which appeared to be even more fragmented and ineffective.

Read the full report:The development of HRH policy in Sierra Leone, 2002 2012  report on key informant interviews