A window of opportunity for reform in post-conflict settings? The case of Human Resources for Health policies in Sierra Leone, 2002–2012

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.

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.

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].

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.

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].

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.

The stages of policy-making in post-conflict Sierra Leone

Figure 1 plots the sequence of Sierra Leone’s main HRH policy and operational reforms over time. It points out to three broad stages in the policy-making process.

The initial post-conflict period was certainly critical to define the trajectory in the reconstruction of the health system and determine the shape of the system in place. It was, for example, the decision not taken to contract-out health services that put the MoHS in charge not only of the stewardship of the system, but also of service delivery. The decision appears to be based on contextual factors. First, the government legitimacy was (more or less) extended to the entire country and its authority recognized by all[4]. This means that the MoHS was recognized to have sufficient capacity to reach all areas, and that public services could be provided safely without the need of delegating to third-parties. More importantly, the influence of the UK, because of the historical relations between the two countries (from the freed slaves’ settlements in Sierra Leone to the active role played by the British Army at the end of the conflict) may have led to a certain pattern in terms of aid and development. DfID preferences in terms of health systems organization may have influenced the decision to opt for direct public provision of healthcare.

However, in the immediate post-conflict, efforts to tackle HRH issues were limited to ‘fire-fighting’ measures, as noted in other post-conflict settings[4, 7]. Rarely were these measures translated into formal, coherent and comprehensive Ministerial policies, as partners adopted a fragmented approach, often implemented without the involvement of the MoHS (for example, by providing salary supplementations or hiring HWs directly). Little or no opportunities opened for strategic reforms, possibly because of the uncertain political context, which is a common feature of post-conflict settings[10, 22, 40].

While these difficulties are generally recognized, some authors suggest that there is a ‘window of opportunity’ for reform in the immediate post-conflict period due to the political energy released by the change of regime, the fluidity of the situation with new players and ideas entering the political arena, and increased funding available[5, 7, 10, 40]. Sierra Leone experienced a prolonged transition at the end of the conflict comparable to that of Liberia and South Sudan, rather than a ‘sudden onset’ of peace[3], but, for example in contrast to Liberia, there was no transitional government. National elections were held immediately after the peace agreement (in 2002) and the government retained a certain degree of legitimacy, control and capacity to provide services[4]. Despite these possibly favorable conditions, in those early years, there was no decision space opening for strategic health system strengthening reforms (including HRH changes), under the weak leadership of the government and the patchy interventions of the development partners. In terms of funding, the National Health Accounts reveal that the donors’ contribution to the Total Health Expenditure (THE) was 146.86 billion Leones in 2004. It then decreased to 109 billion in 2007, but substantially increased to 450.77 billion in 2010. In relative terms, this represented 18% of the THE in 2004, 12% in 2007 and 25% in 2010[52, 53]. The data confirm that, while donor funds were higher in 2004 than in 2007 both in absolute and relative terms, the substantial increase in funding followed the establishment of the FHCI.

Therefore, in the case of HRH policy in Sierra Leone, the ‘window of opportunity’ seems to have opened later than usually recognized and for reasons not necessarily linked to the post-conflict phase, but rather to the momentum created around the FHCI. Indeed, it took about eight years after the official end of the conflict for a second phase of intensive policy-making to begin, brought by strategic reforms for the health system. The disappointingly late onset and slow pace of the reconstruction process has been noted in other contexts. In South Sudan, it took three years after the peace agreement before an actual start to the recovery activities was made[3], while in Liberia the international community was not able to stimulate preparatory steps for an organic health system strengthening reform during the initial 3-year transitional phase, so that another 3 years under the new government had to go by before it was possible to start addressing the reconstruction of the health sector[54]. Also, for the case of Sierra Leone, it was a separate event, i.e. the launch of the FHCI, not related to the post-conflict setting that made it possible to overcome the political uncertainty and bring pressure for change, opening a political ‘window’ for it.

The announcement of the FHCI was the necessary instrumental event and catalyst for action in all respects of the health system, including HRH. This pattern of HRH reform is not uncommon to other contexts, whether post-conflict or not. The most salient moment in this trajectory was the introduction (for reasons mostly external to the health sector) of a broader health financing reform, not specifically focused on HRH, but which had a critical impact on the HRH reform process and was instrumental to it. While Sierra Leone has been one of the few (if not the only) country to explicitly address the link between the removal of fees and the incentives faced by HWs[46], thus making the FHCI more effective (at least, in the design), the fact that a broader health financing reform may be a helpful or even indispensable entry point for HRH reform is a key insight common to other contexts ([22] & KII).

Undeniably, following the introduction of the FHCI, some important progress was made, at least in the design of HRH policies and likely in their implementation and impact on the health system (an evaluation of the effects of the FHCI and related reforms is currently underway). However, below the surface appearance of successful reforms, issues remained for the overall planning and, as noted in other post-conflict settings[22], different HRH-related policies were managed separately with little coordination between donors, as well as within the MoHS, between the different departments.

After the launch of the FHCI and related reforms, a new phase in HRH policy-making can be identified. In this phase, post-conflict issues and features become less apparent. Compared to the previous phase, the pace of HRH decision-making and reforms slowed down, losing the previous momentum. The Working Groups almost stopped meeting altogether and coordination became more difficult. Additionally, with reduced political pressure for the policies introduced after the FHCI, implementation of the policies has not followed the design and there are several problems and delays in their execution.

Features of the policy-making context

The HRH policy trajectory in Sierra Leone shows the role played by historical events and contextual factors in constraining future choices (the concept of ‘path dependency’). As noted in other post-conflict countries, uncontrovertibly “the future health system [is] shaped by the present decisions” ([22]: 665). In the case of Sierra Leone, for example, the fact that the contracting-out approach, which is often adopted in post-conflict settings, was not taken, has affected the subsequent trajectory of policy-making in HRH and beyond. However, despite the fact that some decisions appear irreversible because of how policies developed in previous stages, the Sierra Leonean HRH policy trajectory also shows that it is possible to generate radical reforms in the health sector. As pointed out in the literature, political uncertainty and (politically) fragmented health systems are unlikely to produce “big non-incremental change”. Nevertheless, the realization of propitious conditions could increase the likelihood of such change taking place[55]. In the case of Sierra Leone, the emergence of a powerful initiative, which acted as catalyst both with respect to the internal political will and the external (political and financial) support, was critical to build momentum, open a political ‘window of opportunity’ and create widespread support for radical reform in all aspects of the health system, including HRH.

It could be argued that some elements more common in a post-conflict context facilitated this process. One of these features is the fluidity of power relations and dynamics between influential actors that could facilitate reform. An example of this emerged in our study. While in other countries the professional boards are a powerful actor and the relations between those bodies and the MoH are entrenched in the system, often limiting the space for reform on HRH issues, in Sierra Leone the power relations with the professional associations seemed much more fluid. The Nursing Board, for instance, is chaired by the Chief Nursing Officer (Director of Nursing) at the MoHS, and is by definition aligned to the decisions taken by the MoHS, so that there is less or no opposition to radical changes. No opposition to the introduction of the Sanction Framework came from any of the professional boards on behalf of their affiliates (KII). Secondly, it is possible that because of the state of the health system, the launch of the FHCI could not be based on some relatively minor, incremental measure, but it required wider reforms, including for HRH. It could be hypothesized that in other non post-conflict contexts, such reforms could be postponed or diluted over time, while in a reconstruction context, the gravity of the situation, accompanied by the general climate of reform, renovation and change could foster new initiatives and gather national and international support around them. Indeed, similarly to South Africa in 1994 where the post-crisis situation created both an opportunity and a need for dramatic change[56, 57], Sierra Leone has enjoyed high levels of political interest and pressure. This was coupled with substantial donor funding and technical assistance, while in other sub-Saharan Africa countries free health care initiatives were introduced without generating such momentum (as for example in Burundi, Burkina Faso, Ghana, Senegal, Sudan and others[58–64]). The reasons are likely to be related to the combination between (i) the national political conjuncture under the new government interested in implementing a visible and successful flagship reform, (ii) the international momentum around the improvement of Maternal and Child Health and the introduction of fee exemptions, as well as the major role played by some donors, and especially by a donor such as the UK with close historical ties to Sierra Leone, and (iii) the health needs of the population (in particular, with reference to the high maternal mortality levels).

Other features of the policy-making environment that our analysis highlights are less specific to the post-conflict context. It could be argued that they are not qualitatively different from those in low-income settings, but that perhaps the differences are only quantitative (i.e. same issues but worse) or, in fact, negligible. One such feature relates to the role of external actors in influencing the policy-making processes, which occurs in non post-conflict settings and is well documented in post-conflict where governments are under-resourced and weak[3, 10, 40, 54, 65]. Sierra Leone is no exception and, although evidence and health needs certainly played a role, the approach adopted for decision-making seems to be a pragmatic one, where the critical issue of the availability of funding allowed space for donor influences. Also, some HRH measures, such as the reorganization and management of the payroll, received high levels of donor-funded technical assistance, which may have allowed their realization, but raises concerns around their sustainability in the longer-term. Additionally, despite the noteworthy increase in the alignment of partners to the ministerial policies during the preparation of the FHCI, there appear to be some disconnections between the different actors. The fragmentation of views and agendas was partially overcome by the urgency to make decisions at the time of the launch of the FHCI. However, the lack of coordination became problematic later on, as the political pressure for rapid reforms was reduced. The result was fragmented policy-making, a set of policies that are not completely coherent and a largely ineffective implementation of some of those policies[10]. Moreover, reforms remained incomplete as the adoption and implementation of other necessary measures (e.g., recruitment and deployment of HWs, improved pre-service training and development of non-financial incentives) were not pursued or pursued in a slow and partial manner.

Finally, the apparent success of Sierra Leone in addressing HRH issues by taking advantage of a window of opportunity for reform cannot hide the evident challenges of having HRH changes pushed forward by a short-lived political pressure. As a consequence of the urgency of the reforms, preference was often given to one-off exercises, such as the mobile recruitment, or shorter-term solutions (as for example the decision to overlook pre-service training or the postponement of the introduction of the remote allowance). Similarly to other settings[65], much attention was generated around the design of the policies, while far less was given to their implementation at local level, which remains problematic, despite some innovative features, such as use of civil society monitors at facility level^d.