Immediate post-conflict context and HRH challenges
By the end of the conflict in 2002, the situation of the health system was extremely challenging. Concerning HRH, little data and documentation exist and those available are often unreliable and contradictory[29]. As one respondent noted, this reflects the fact that all actors were primarily concerned with the pressing needs of the early recovery and little time was available for the production of documents and reports, and even less for academic research.
The available information shows that the challenges faced at the time in Sierra Leone are not dissimilar to those in other post-conflict contexts[7, 10, 29]. The basic health infrastructure was destroyed and most services were completely disrupted, especially in the eastern and southern part of the country where most of the rebel activity took place. Health facilities were grossly understaffed as many HWs had left the country, and particularly those in the higher cadres. Other HWs were employed by NGOs or held dual positions with NGOs and the MoHS[30]. The majority of those HWs who stayed in the government service preferred to work in Freetown or in the Western Area around the capital. The data available for that period clearly indicate a significant loss of qualified HWs in the public health sector in Sierra Leone which created a gap that remained to be filled in the aftermath of the conflict. Of the 203 Medical Officers that were present in the country in 1993, only 67 remained in 2005 and of the 623 State Registered Nurses (SRN) 152 remained[31]. While the private sector employed only a small minority of the health workforce, centered in the capital, in the few years immediately after the conflict, many HWs in the public sector were working with NGOs in the governmental facilities, for which they would receive incentives and training, whether under a formal agreement with the MoHS or without. NGOs supporting public facilities also recruited and funded personnel, which was later absorbed in the MoHS payroll.
In those early years, the extreme lack of coordination between the different actors in the health system appears to be an important feature of the policy context. The term ‘chaos’ frequently emerged in the respondents’ narratives:
“What happened was, during a period of chaos, most of the NGOs were operating on their own” (KII - MoHS).
“After the war, it was complete chaos. The NGOs came and went […]. They employed the nurses directly, without even consulting the Ministry. […] They never presented any budget. But this was a war. We had to bend backwards in the Ministry” (SM – MoHS).
This highlights the fragmentation of the health system at this stage and the struggle that the government through the MoHS faced to create a system and establish control over the health workforce. However, it seems that the MoHS was able to maintain a certain leadership to start the process of reconstructing the public health system. For example, in contrast to other countries in similar post-conflict situations[6, 32–34], in Sierra Leone health services were provided by public facilities and were not contracted-out to other actors of the health system. Although the choice of not adopting a contracting-out approach did not appear to be made explicitly by any of the actors but was rather the consequence of the specific context, it clearly had lasting consequences which affected the future development of the healthcare system.
The development of formal HRH policies: 2002–2009
Against this backdrop, HRH reforms began to develop. Our findings reveal that between 2002 and 2009 the progress towards policy-making for a coherent restructuring of the health workforce was not rapid or effective. Although the challenges were correctly identified by the MoHS and potential solutions being proposed (cf. for example[30, 35]), very little was happening in practice.
Relatively minor changes were introduced to improve the management of HWs in order to keep the system functioning. For instance, between 2006 and 2007, the Scheme of Service was reviewed to ensure a clearer career path and HWs started receiving allowances for housing, remote area placements, and leave[35, 36]. However, the major reforms suggested in the annual presentations of the MoHS HRH Manager and in other informal MoHS documents[30, 35], remained unfunded and unimplemented and the response to the HRH challenges was fragmented. At the same time, a series of broad policies and strategies were being drafted – in 2002 the National Health Policy (NHP)[37], followed by the Human Resources for Health Development Plan 2004–2008[38] and then the Human Resources for Health Policy in Sierra Leone[39]. Similar to other post-conflict contexts, these documents tended to remain relatively vague normative frameworks rather than operational documents to be reflected in changes at peripheral level[7, 22, 40]. As the most recent HRH Policy (2012) states, “there have been two attempts to formulate national policy to guide the development and management of Human Resource for Health in Sierra Leone […], but none was finalized or adopted for implementation” ([41]: p.6). The lack of technical and implementation capacity within the MoHS could explain why policies remained on paper. Additionally, external agencies played a significant role in this, in particular because their mandate narrowly focused on production rather than implementation of the strategies. Some key informants pointed out to the fact that these policies were externally-driven, lacking the national ownership that would ensure their effective implementation:
“People started working on their own areas and they started developing a policy and plan and things like that […]. But it was all happening in parallel, also depending […] on the focus of donors to provide TA and funding for certain things. So I think a lot of policies applied at the beginning were definitely donor-driven. WHO said ‘you don’t have a policy on this and this. We have to develop it’ , and you’ll get it.” (KII - NGO).
The piecemeal support of the international community did not allow for the strengthening of the MoHS, especially as donors focused on ‘their’ programmes, supporting one or another department or units, undermining the overall capacity of the MoHS and creating a fragmentation within the Ministry, with long-lasting consequences[4].
Among the reasons for the delay in the adoption and implementation of major shifts in HRH policy may be the lack of clear political vision on the future of the health system more broadly. Indeed, key informants agree that in the years following the conflict, strategic policies and plans were slow to be put in place or missing altogether.
“The main issue during this time [was that] the Human Resources Strategic Plan was not adequately addressing the issues of Human Resources. Because of the absence of a strategic plan, we were just swimming with ideas […] and there was no clear direction as to what to do.” (KII – donor).
“Let me tell you something, in life when you do not have a goal you are working towards and you go purposeless, aimless, you’re slow at it.” (KII – MoHS).
The consequence of the lack of political guidance and strategic vision was a general sense of ‘purposelessness’. This resonates with the findings of the documentary review, where it emerged how fluid and uncertain policy context was, as explicitly recognized by the HRH Development Plan 2004–2008 which states that a certain flexibility will be allowed in the proposed activities “given the current level of uncertainty regarding the exact nature of the reforms” ([38]: p.80 – italics added). Obviously, the broader political dimension is important to understand the lack of strategic vision for the health sector. The government elected in 2002, which seemed to initially enjoy some support, soon lost much of its popularity given its weaknesses in terms of leadership to drive for reform, especially compared to the following administration in power from 2007 ([4] & KII). For the HRH sector, the consequence of drafting broad policies without an overall vision on the ways to rebuild and strengthen the health system was a relatively static approach, which left little space for innovation and focused mostly on “fire-fighting”, as suggested by a respondent, i.e. tackling the most immediate issues with quick-fix solutions. The situation substantially changed with the introduction of the ‘free health care initiative’ (FHCI).
The introduction of the FHCI: 2009–2010
In September 2009, the President of Sierra Leone, Ernest Bai Koroma, announced at a donors’ conference in London his intention to launch a reform to introduce free healthcare for pregnant women, lactating mothers and children under 5 years of age[42]. Soon after, the announcement was made in Sierra Leone to the MoHS and partners and an official launching document was drafted[43]. A few months were allowed to prepare the launch of the new policy in April 2010. Without doubt, the introduction of the Free Health Care Initiative (FHCI) is the key event that emerged from the document review and that informants consistently mentioned in their narratives about the reconstruction of the health sector.
Different factors emerge as the ‘drivers of change’ for this reform. Certainly, the health status of the population with one of the highest maternal mortality rates in the world, as well as emerging evidence of financial barriers in access to healthcare, played an important part in promoting the policy ([44] & KII). However, even more critical seems to be the role of the President and the lead he took to include the FHCI among the government’s priorities. The political dimension of the FHCI is confirmed by the President’s direct involvement in the announcement of it as a ‘Flagship Project’, by the work done by the Strategy and Policy Unit, a very influential, high-level advisory unit in charge of promoting the presidential agenda[42], as well as in numerous interviews. Additionally, the international environment and the pressure from external actors also contributed to the decision. Indeed, free healthcare was at the time an increasingly popular reform in many African countries, supported by some of the international donors, and in particular the UK Department for International Development (DfID), which also made funding available tied to the implementation of this particular reform. As one informant stated:
“You have to have it [the FHCI] in context. I know that there was a push in 2008/2009 by Gordon Brown and he decided, DfID decided to support [the reform]. And because of DfID support, […] that is why it was able to get off. Under our government’s own resources they could not [support it].” (KII – MoHS).
The launch of the FHCI provided an opportunity for health system strengthening and to address in a more comprehensive and organic way the issues that previously were partially solved with piecemeal changes. The design and preparation of the FHCI (much more than its implementation) represented an occasion to increase and improve coordination among actors and provide a broad, common objective to all stakeholders (KII). Six Technical Working Groups were put in place, of which one focused on HRH, which held meetings weekly and were tasked with designing the necessary reforms, as well as of coordinating among the different partners[45].
With reference to HRH, the launch of the FHCI played an instrumental and catalytic role in pushing reforms. It was explicitly recognized by all stakeholders that addressing issues affecting the health workforce was critical for the success of the FHCI, for at least two reasons: firstly, HWs would have to deal with an increased workload; and secondly, in order to compensate facilities and HWs for the loss in revenues due to the end of the cost-recovery. With the inputs from the Working Group, HRH reforms started developing. The result was that, by April 2010, salaries had been increased for all HWs in technical positions. The increase was substantial, ranging from 314% for the lower grades up to 705% for the higher grades[46]. As a corollary to the salary increase, an in-depth verification and cleaning of the MoHS payroll was carried out to ensure that only legitimate staff were included and to eliminate ‘ghost workers’[47]. Additionally, a mobile recruitment programme at district level was put in place for the fast-track recruitment of new workers and of those already volunteering in the facilities[47]. At the same time, discussions began about the introduction of a system to monitor the presence of HWs in the facilities, which was later introduced in mid-2010 when staff absence begun being monitored through the Attendance Monitoring System, and January 2011 when the Sanctions Framework was implemented[48].
Obviously, the decision-making process that led to the choice, design and implementation of these reforms was less smooth and linear that it would appear from the end results. While the creation of inter-agency working groups undoubtedly increased coordination, some issues were hidden under the surface. As one respondent recalls,
“Of course we had our Working Group meetings and we would talk, but these were the ‘big lines’. If you go to the little activities, we were not so well coordinated”. (KII – NGO).
In particular, concerns emerged around the role of the donors, their different views on FHCI and on how different components of the health system could be reorganized to provide free health services. In particular, the argument between two donors around the merits of a salary increase compared to the introduction of a performance-based financing (PBF) scheme stalled the discussion for some time. As a key informant recalls,
“These meetings [of the HRH Working Group] were completely dominated by [two donors] having their ideological fight effectively. I mean, it wasn’t just those two individuals but these meetings achieved very little, because, when these two big donors are busy having a fight, week after week after week not much else gets discussed.” (KII – TA).
In the end, while conflicting agendas and ideologies may have played a role in the decision, the choice of policy approach (i.e. the salary increase) was ultimately taken on the basis of practical feasibility. Although it was recognized that PBF would have had the advantage of improving the accountability of HWs, it was also agreed that setting up a PBF scheme would have higher transaction costs and take longer than a salary increase. This was perceived as a major disadvantage given the urgency of the launch of the FHCI (KII – donor). Moreover, after a nation-wide HWs strike which took place in March 2010 in request for higher salaries, this option became inevitable. What emerges from the analysis is that the MoHS perspective seemed to have been caught in the cross-fire of the donors’ agendas and the funding possibilities that came with donors’ support. It also appears that the corollary measures taken, such as the payroll cleaning and the introduction of the Sanctions Framework, were not only strategies to improve the HRH management and performance, but also a conditional request from the donors funding the reform, and DfID in particular, in order to “protect their investment” and “minimize risk” of misuse of their funds (KII – donor).
Several episodes confirm the influence of external actors, as well as the fragmented and ‘serendipitous’ nature of policy-making at the time. Many respondents recognized the drawbacks of the technical assistance provided, characterized by high turnover and little coordination, which resulted in the loss of institutional memory, duplications and incoherence in policy-making and implementation. This is, for instance, the case with the cleaning of the MoHS payroll which was done in 2009–2010, but had already been carried out a few years before for the entire civil service ([49] & KII). Providing another example, some informants recalled how, despite the pressures and promises of some partners, the issue of funding the salary increase, was resolved in an “entirely coincidental” way (KII – TA), when the Global Fund’s Health System Strengthening funds became available. Interestingly, the Global Fund had not participated in the Working Group’s discussions directly and its low level of engagement contributed to creating a commonly accepted narrative around the role of donors, where DfID (contributing, over three years, about 22% of the total health salaries after the increase, but highly involved in the discussion and providing substantial, direct support to the MoHS through numerous technical assistants) took a much more central role and was able to steer critical decisions, than the Global Fund (contributing 20% of the total amount, in the initial 3 years)[50].
HRH policy-making after the Free Health Care Initiative: 2011–2012
Beyond the urgency of the FHCI launch, the momentum for the collaboration between MoHS and partners seems diminished, if not lost, afterwards. The Working Groups are reported to meet much less regularly after the launch of the FHCI and were almost inactive by March 2013. Nevertheless, two major reforms were implemented after 2010, which in fact had been discussed or planned at the time of the FHCI design: a Performance-based Financing (PBF) scheme and a Remote Allowance for HWs working in rural posts.
While the discussion of a PBF scheme became detached from the design and the planning of the FHCI as the salary increase option was preferred, meetings for the planning of PBF continued, especially between the World Bank and the Department for Planning and Information (DPI) of the MoHS. The scheme was designed and has been implemented since April 2011. Along with the World Bank, which as the promoter and the funder of the scheme is recognized to be the driving actor for its implementation, the DPI also played a critical role and remains in charge of the operationalization of the policy. In contrast, the Department for HRH (D-HRH) which is in charge of the payroll management (which, incidentally, is supported by a different donor) is far less involved in the scheme and has surprisingly little overview of the working mechanisms of PBF. The consequence of this is a further fragmentation, not only in terms of the design of the HRH policies and the package of incentive for HWs, but also of the implementation of the PBF scheme. This has been plagued with severe delays in the payments made to the facilities, which undermine the effectiveness of the scheme and may have had negative consequences on the performance of the HWs (KII).
A similar story applies to the Remote Allowance for HWs, which was introduced in early 2012. This policy had already been discussed before the launch of the FHCI; however, it was not implemented because of the lack of resources. As further funding from the Global Fund became available, the policy was finally designed and introduced. Again, the DPI is mainly responsible for its implementation and, despite some collaboration with the D-HRH to access payroll data, there appears to be a strict division of tasks between the two departments, with little transparency in its management. As a consequence, few actors seem familiar with the mechanisms for eligibility and funding. Furthermore, the Remote Allowance currently rarely reaches the HWs that are eligible for it, due to the discontinuity of the Global Fund funding, as well as the poor communication and coordination within the MoHS (KII). The separate management of the Remote Allowance creates a further fragmentation of policies and activities, even within the MoHS.
Beyond these two major reforms (and their implementation challenges), several HRH issues remain unsolved or only partially addressed. For instance, during the preparation for the FHCI, a mobile recruitment programme had been set up. However, this remained a one-off exercise. For the routine recruitment of HWs, the establishment of a Health Service Commission (HSC) was planned to replace the Human Resources Management Office (HRMO). Despite the HSC being established by a Governmental Act in 2011 and the Commissioners being nominated, the HSC appears to be still not functional in March 2013. Similarly, pre-service training has been overlooked in the rush for the launch of the FHCI, in order to focus on aspects that it was possible to address faster (e.g., recruitment of HWs and in-service training). In-service training proliferated in an uncoordinated manner and only in early 2014 was the D-HRH of the MoHS preparing an HRH Training Plan for the next 10 years, to ensure the standardization and coordination of both pre-service and in-service training. Additionally, the role of non-financial incentives for the motivation of HWs, and in particular for those in rural postings, also emerges as largely ignored by policy-makers.
In terms of official MoHS policies, while the documents prepared before 2009 have remained mostly on paper, as described above, those approved following the launch of the FHCI, and in particular, the Human Resources For Health Policy and the Human Resource for Health Strategic Plan 2012–2016[41, 51] seem to have been prepared to give an ex-post, official shape to the changes that had already taken place at operational level in HRH strategies.