The Free Health Care Initiative: how has it affected health workers in Sierra Leone Sophie Witter, Haja Wurie & Maria Paola Bertone Contents List of tables ........................................................................................................................... 4 List of figures .......................................................................................................................... 4 Acknowledgments...................................................................................................................... 5 Acronyms ................................................................................................................................... 6 Executive summary .................................................................................................................... 7 Introduction ............................................................................................................................. 11 Methods ................................................................................................................................... 12 Study design ......................................................................................................................... 12 Study areas ........................................................................................................................... 12 Research tools ...................................................................................................................... 12 1. Career histories of health workers ............................................................................ 12 2. Key informant interviews .......................................................................................... 14 3. Health worker survey ................................................................................................ 15 4. Document review ...................................................................................................... 17 5. Secondary data analysis ............................................................................................ 19 Research ethics..................................................................................................................... 20 Study limitations................................................................................................................... 20 Findings .................................................................................................................................... 21 Context of HRH in Sierra Leone pre-FHCI ............................................................................. 21 Availability and retention challenges ............................................................................... 23 Performance challenges ................................................................................................... 24 HRH policy objectives and approaches ............................................................................ 25 FHCI – announcement and preparatory phase .................................................................... 28 The link between the FHCI and subsequent human resource policies ................................ 30 Description of key HRH policy changes ................................................................................ 32 Issues and challenges in the decision-making process ........................................................ 39 Implementation of policies .................................................................................................. 43 Financing and sustainability of policies ................................................................................ 48 Impact of policies ................................................................................................................. 51 Health workers perception of impact of FHCI on health system ..................................... 51 Payroll cleaning ................................................................................................................. 58 Salary uplift ....................................................................................................................... 58 Staff sanction framework ................................................................................................. 61 Performance management contracts ............................................................................... 63 Performance based financing ........................................................................................... 63 Remote allowance ............................................................................................................ 70 Changes in numbers, attrition and density ...................................................................... 72 The current situation of health workers .................................................................................. 76 Workload .......................................................................................................................... 76 Remuneration ................................................................................................................... 77 Outstanding challenges for HRH .............................................................................................. 83 Production and training challenges ..................................................................................... 84 Recruitment and deployment of health workers ................................................................ 86 Distribution challenges ......................................................................................................... 90 Incentives (non-financial and financial) ............................................................................... 91 HRH management challenges .............................................................................................. 93 Discussion................................................................................................................................. 93 Conclusions .............................................................................................................................. 95 References ............................................................................................................................... 97 List of tables Table 1 Career history sample, Sierra Leone health workers .................................................. 13 Table 2: Sampling frame of HWs by district (total number, original planned sample, actual sample) ..................................................................................................................................... 16 Table 3 Themes and subthemes identified and used for thematic analysis (document review and KII) ..................................................................................................................................... 19 Table 4 Availability of MoHS medical personnel: 1993-2005 .................................................. 23 Table 5 Calculations for the Remote Allowance ...................................................................... 38 Table 6 Breakdown of financial support to salary increase ..................................................... 50 Table 7 Redeployment of HWs to the Districts ....................................................................... 58 Table 8 Salaries (including allowances) for 3 cadres of HWs (Leones per month) .................. 59 Table 9 Number of PBF payments received, by place of work (n=138) [column %] .............. 64 Table 10 Average quarterly PBF payment (mean max min sd), by profession (n=110) ......... 66 Table 11 Number of hours worked per week by profession ................................................... 76 Table 12 Number of patients seen per week, by profession ................................................... 77 Table 13 Salary received last month, by profession (mean, max, min, sd) (n=300) ............... 77 Table 14 Salary received last month (mean), by profession and gender (n=300) ................... 79 Table 15 Payment from user fees received (min, max, mean, sd), by profession (n=13) ....... 79 Table 16 Other payments received (min, max, mean, sd), by profession (n=15) ................... 80 Table 17 Total income from all sources (main employment) last month – min, max, mean by profession (n=269) ................................................................................................................... 80 Table 18 Progress on 2010 targets of the HRH pillar of the NHSSP ........................................ 83 Table 19 MoHS Health Professionals (2011) ........................................................................... 86 Table 20 Distribution of publicly-employed medical officers (2011) and SRNs (2010) ........... 90 List of figures Figure 1 summary of characteristics of key informants interviewed (ReBUILD KII, Sierra Leone) ...................................................................................................................................... 15 Figure 2 Type of documents retrieved, Sierra Leone HRH ReBUILD study .............................. 18 Figure 3 Date of publication (ReBUILD document review) ...................................................... 18 Figure 4 Timeline of major health policy and HRH reforms in Sierra Leone, 2002-12 ............ 26 Figure 5 Number of PBF payments received, by profession (n=138) ....................................