Serving through and after conflict: life histories of health workers in Sierra Leone
Haja R Wurie,Sophie Witter
Coherent human resource for health (HRH) policies should be designed to address the challenges faced in recruitment and retention of health workers, particularly in developing countries. In Sierra Leone, there are challenges in providing equitable healthcare for all due in part to the current HRH situation, which includes an unequal distribution of the health workforce between urban and rural areas. There is therefore an urgent need for evidence based research that is policy driven and relevant to guide the Ministry of Health and Sanitation (MOHS) to effectively plan, manage and utilise its valuable human resources.
Thus, to document the evolution of incentives for health workers post-conflict and their effects on HRH and the health sector and to derive a recommendation package for retention of rural health workers from a health worker’s perception, a qualitative study involving in-depth interviews with health workers was conducted by ReBUILD in 2012-13. 23 public sector health workers of different cadres, working in four regions, were interviewed. The study used a life history approach to explore health workers’ experiences over time, including their decision to join the health professional workforce, the choices they made in taking jobs, their satisfiers/dissatisfiers, their experience of conflict, and their perceptions of the effectiveness of different policy measures. These themes were analysed taking gender, urban/rural and cadre of health professional differences into account.
In general, retention challenges in the health sector of Sierra Leone can be attributed to the level of income earned not being in line with the cost of living, non-implementation of HRH incentive policies where they exist, problems with deployment and management of personnel (including political interference in postings, poor relationships with colleagues and the administrative hierarchy in relation to discipline and career management), poor systems for motivation, poor working conditions, limited provision for individual professional capacity development (with regional disparities in urban versus rural) and the lack of an appropriate retention package for rural posted health workers. Financial incentives alone are not enough to motivate health workers in rural areas. Reasons behind poor retention of health workers in rural areas include the lack of accommodation, lack of access to basic amenities for personal and professional use, weak transport infrastructure and irregularities in financial incentive packages.
The study has provided useful policy driven insights into how health workers perceive their professional careers and the incentive environment in Sierra Leone, which can be utilised by policy makers in the development of a long-term HRH development plan for quality service delivery.
Some of the recommendations arising from the study include the following:
1. The recruitment process for health workers in Sierra Leone is too centralised and sometimes causes inordinate delays, allowing local managers no role in staff selection and performance management. This should be addressed as part of the establishment of the new Health Service Commission, whose mandate is to recruit human resource for health (HRH). Decentralisation of the process might also reduce the time which is currently taken to engage new staff, something which causes demotivation and attrition.
2. A full package of measures should be introduced to address the rural/urban divide for health staff. These should go beyond the currently erratic RAA to include: specific tours of duty (e.g. 9 | P a g e two years), which are respected; preferential training access for those who are working in rural areas; and provision of housing close to facilities (especially for female staff, for security reasons)
3. Routes into the medical profession for those of low income should be encouraged as it is likely that these staff, especially if mid-level, will more easily be retained in rural areas.
4. The development of a career structure with options for progression in pay and responsibility for CHOs should be developed (e.g. through the Scheme of Service which is currently being developed for for Health Workers in Sierra Leone).
5. The PBF scheme should be reformed so that payments are regular (monthly, rather than quarterly), paid on time, and transparent. It was clear that as well as the financial top-up, health workers appreciated getting feedback on their work in the form of an appraisal system, and a way of providing this in a supportive way should be built into the PBF process.
6. The issue of controlling political interference is more delicate but could be addressed through the new Health Service Commission as well as through organisational culture changes of a broader nature.
7. The RAA should be reviewed to establish the additional costs of living and working in rural areas. It is not just a motivation scheme but also needs to cover the extra costs which health workers face. Greater involvement in its design would also ensure that health workers understand how it is meant to operate.
Read the full report: Serving through and after conflict: life histories of health workers in Sierra Leone