1.
ReBUILD’s human resources for health research
Meeting
28th January 2016
Hill Valley Hotel, Freetown
Evidence for supporting a health workforce
for all in Sierra Leone
College of Medicine and Allied Health Sciences

2.
Morning sessions
 Welcome and opening remarks
 Presentations:
 Introduction and overview of ReBUILD and its HRH research
 Evolution of HRH policies
 Organisational statements
Tea break
 Presentations of ReBUILD research
 Experiences of incentive policies for health workers
 Remuneration structure of primary healthcare workers
 Summary of policy recommendations

3.
ReBUILD is a 6 year £6million research project funded by the UK Department for International Development (DFID)
Research on health worker policies,
incentives and retention in post-conflict
countries: overview of ReBUILD’s work in
Sierra Leone
Sophie Witter on behalf of ReBUILD team
Funded by

4.
Key starting points
Post conflict is a
neglected area
of health
system research
Opportunity
to set health
systems in a
pro-poor
direction
Focus on HRH
and health
financing but
also on health
system/state
building links
Choice of
focal
countries
enable distance
and close up
view of post
conflict
Decisions made early post-conflict can steer the long term
development of the health system

5.
Background
 Importance of decisions made or not made in post-
conflict period in resetting health sector
 Health workforce as crucial component in sector
reconstruction
 No research on this topic in SL prior to ReBUILD
 Field work conducted 2012-14
 Analysis extended to cover Ebola crisis

6.
Aims and research questions
To understand the evolution of incentives for health
workers post-conflict and their effects on HRH and the
health sector
Health systems
How have HR
policies and
practices evolved
in the shift away
from conflict?
What influenced
the trajectory?
What have been
the reform
objectives and
mechanisms?
Health workers
How the incentive
environment has
evolved and its
effects on health
workers?
What lessons can be learned (on design, implementation, and suitability to
context) of different incentives, especially for post-conflict areas?

7.
Summary of research tools
Research tools Cambodia Sierra Leone Uganda Zimbabwe
1. Stakeholder mapping √ √
2. Document review √ √ √ √
3. Key informant interviews √ 33 √ 23 main project
19 Ebola phase
√ 25 √ 14
4. Life histories/ in-depth
interviews with HWs
√ 24 √ 23 main project
24 Ebola phase
39 Affiliate project
√ 26 √ 34
5. Quantitative analysis of routine
HR data
√ √ √
6. Survey of health workers √ 310
266 PHWs (affiliate)
√ 227
Witter, S., Chirwa, Y., Namakula, J., Samai, M., So, S. (2012) Understanding health worker incentives in post-conflict settings:
study protocol. ReBuild consortium.
http://www.rebuildconsortium.com/media/1209/rebuild-research-protocol-summary-health-worker-incentives.pdf

8.
Research sites
 Western Area (Urban/Rural)
 Kenema (Eastern Region)
 Bonthe (Southern Region)
 Koinadugu (Northern Region)
 Also affiliate project in Bo,
Kenema and Moyamba

9.
Research outputs
Online reports available on the ReBUILD website:
 Stakeholder mapping report
 The development of HRH policy in Sierra Leone, 2002-2012 – a document review
 Serving through and after conflict: in depth interview report
 Health Workers incentive: survey report, Sierra Leone
 The development of HRH policy in Sierra Leone, 2002-2012 – report on key informant interviews
FHCI
 Staffing the public health sector in Sierra Leone, 2005‐11: findings from routine data analysis’
 The Free Health Care Initiative: how has it affected health workers in Sierra Leone
Peer reviewed publications:
 Wurie, H., Samai, M., Witter, S. (2016) Retention of health workers in rural and urban Sierra
Leone: findings from life histories. Human Resources for Health journal
 Bertone, M. and Witter, S. (2015) An exploration of the political economy dynamics shaping
health worker incentives in three districts in Sierra Leone. Social Science and Medicine, volume
141, pp56-63.
 Witter, S., Wurie, H. And Bertone, M. (2015) The Free Health Care Initiative: how has it affected
health workers in Sierra Leone? Health Policy and Planning journal, 1-9
 Bertone, M., Samai, M., Edem-Hotah, J. and Witter, S. (2014) A window of opportunity for reform
in post-conflict settings? The case of Human Resources for Health policies in Sierra Leone, 2002-
2012. Conflict and Health, 8:11.

10.
Overview of day
 Evolution of HRH policies
 Short organisational statements
 Impact of incentive policies on staff, and what
motivates/demotivates them
 Understanding the complex remuneration structure of
primary health staff
 Overview of research recommendations
 Current priorities and debates for reform within the D-
HRH and HRH WG and evidence needs
 Panel discussion and way forward

11.
ReBUILD is a 6 year £6million research project funded by the UK Department for International Development (DFID)
Windows of opportunities
Lessons learned on policy-making from post-conflict
Sierra Leone (2002-2012)
Maria Bertone
London School of Hygiene and Tropical Medicine & ReBUILD
maria.bertone@lshtm.ac.uk
Funded by

12.
Documentary review
(n=76)
Interviews with key
informants at central
level
(n=23)
Research tools
Longitudinal study
to explore the HRH
policy making
trajectory in post-
conflict
Sierra Leone
2002-2012
Case study Research questions
1. How have HRH policies
evolved in the shift away
from conflict?
2. What influenced the
trajectory? What are the
drivers of policy making?
What defines the timing
and the political space for
reform?
3. What lessons can be
learned?
Research questions and methods
Half-day stakeholder
meeting
(23 participants)

13.
Three phases of HRH policy-making
2009 2010 201220112006 2007 2008
First phase: early development of HRH policies
Second phase: launch of
FHCI and related HRH
policies
Third phase: post-FHCI policy-
making
2002-2009 2009-2010 2011-2012

14.
First phase: 2002-2009
 ‘Fire-fighting’ phase: many players (NGOs) and limited control by
the MoHS; broad HRH policies developed but limited ability to
implement them; limited data
“After the war, it was complete chaos. The NGOs came and went […]. They employed the
nurses directly, without even consulting the Ministry. […] But this was a war. We had to
bend backwards in the Ministry” (SM – MoHS).
 Official documents highlight challenges and describe potential
solutions, while they rarely propose actual implementation plans
 Fluid and uncertain policy context
The HRH Development Plan 2004–2008 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” (p.80 – italics added).

15.
Second phase: 2009 - 2010
 Strengthening and reforming phase: FHCI triggered series of
sectoral and HRH changes
 Improved coordination (HRH working group) and specific TA for the
design of necessary HRH reforms
 Several-fold increase of HWs salaries (2010)
 Introduction of a Staff Sanction Framework to reduce absenteeism (2010-11)
 Payroll cleaning (2010) – 850 ghost HWs were removed (~12% of total), 1,000 new
HWs added
 Fast-track recruitment at district level (2010)
 As the implementation of reforms became more coherent and
operational, budgeted plans and expenditure frameworks begun
to appear.
 Substantial donors’ funding to sustain these reforms (DfID and GF)

16.
Third phase: 2011-2012
 Reforms discussed during FHCI preparation are introduced :
 Implementation of a Performance-Based Financing scheme in PHUs (2011)
 Introduction of a rural allowances for health workers in remote posts (2011)
 Performance contracts introduced for Ministers, Permanent Secretary and
Directors (2011-12)
 New HRH Policy and HRH Strategic Plan (2012)
 Official documents which give ex-post shape to the reforms and changes that
had already taken place at operational level
 Pace of change slowing after 2012: less momentum and many
implementation challenges

17.
Policy drivers and enablers
 Introduction of the FHCI
“I believe, for the past 10 years, that free health care was a big turning point, because
before gradually everything was coming up. The free health care was big turning point to
accelerate the improvement” (KII – donor).
 High-level political pressure and leadership.
 Development partners’ funding, but also consensus to back the
initiative by all major players
 Donor support allowed for high level of ad hoc TA which enabled changes to be
operationalised.
 Sense of need for change

18.
Issues and remaining challenges
 Urgency in the design and not enough time to discuss all
possible options
 Preference for one off strategies and short term policies
 Focus on the design, and less attention to implementation
 Sustainability of the reform in the long run, when technical and
financial support will diminish
 Reforms based on short-lived political pressure
 Health system remained fragile

19.
Lessons learned
 Windows of opportunity for reform do not ‘automatically’
open after conflict or crisis
 They are more likely to occur given some features of the
context:
 Strong and sustained political leadership and clear strategic
orientations
 Aligned external support
 Coordination between actors is key.

20.
Lessons learned (2)
 Attention to avoid challenges of post-FHCI policy making
 Careful design and assessment of all options
 Engage and plan long-term and include long-term reforms (e.g.
training)
 Pay attention to implementation issues
 Ensure regular M&E of reforms and flexible adaptation if needed
 Sustain momentum for reform after the initial period

21.
This presentation is based on the paper:
Bertone MP, Samai M, Edem-Hotah J and Witter S (2014),
A window of opportunity for reform in post-conflict settings? The
case of Human Resources for Health policies in Sierra Leone,
2002-2012. Conflict and Health, 8: 11.
Available at http://www.conflictandhealth.com/content/8/1/11
www.rebuildconsortium.com

22.
Haja Ramatulai Wurie
Research Officer
ReBUILD/College of Medicine and Allied Health Sciences –
Sierra Leone
Experiences of incentive policies and challenges for
retention and motivation of health workers, post-
conflict and during EVD
Funded by

23.
Structure
 Health worker experiences – incentive policies
 FHCI
 Salary uplift
 RAA
 PBF
 Risk allowance during EVD
 Motivating and demotivating factors (urban vs rural; male vs female)
 Post conflict
 During EVD
 Coping strategies
 Outstanding HRH challenges
 Lessons learnt for the post EVD reconstruction phase
24

24.
Effect of FHCI HRH reforms
Staff sanction framework -
Rates of reported
unauthorised absenteeism,
Sierra Leone health workers,
2011-14
-1%
4%
9%
14%
Dec-10
Mar-11
Jun-11
Sep-11
Dec-11
Mar-12
Jun-12
Sep-12
Dec-12
Mar-13
Jun-13
Sep-13
Dec-13
Unauthorised
Absenteeism
0
0.01
0.02
0.03
0.04
0.05
0.06
0.07
2005 2006 2007 2008 2009 2010 2011
Healthprofessionalper
1000inthepopulation
Medical and nursing staff per population, Sierra Leone
Medical
staff
Nursing
staff
For more information, see:
for Health policies in Sierra Leone, 2002-2012. Conflict and Health, 8:11. Witter, S., Wurie, H. And Bertone, M. (2015) The Free Health
Care Initiative: how has it affected health workers in Sierra Leone? Health Policy and Planning journal, 1-9

25.
Experiences and perception of incentive
policies – FHCI (positive effects)
Health worker
 Increased motivation
 Improved quality of
service given
 Increased training
(mostly donor support)
‘
Health system
 Improvements in the health
facilities
 Increased service utilisation
‘For the health facilities, people are now making
use of the facilities even the maternal beds
compared to before’ (Female, Bonthe, IDI-1)
 Increased institutional
deliveries
‘with this free health we have laws, that no
women should deliver with TBA. […] now if you
deliver any pregnant woman at home you are
going to be fined’(Female, Koinadugu, IDI-10)

26.
Experiences and perception of incentive
policies – FHCI (negative effects)
 Increased workload
‘[…] the work is strenuous, before this time people were not coming because of finance
but now after removing users fees people are coming 24hours’ (Male, Koinadugu,
IDI-11)
‘…. we had problems already …and now we have enormous amount of patients
coming, lack of adequate supplies, drugs are short, materials are not there and then
these patients come and the old challenges I have already mentioned are still in place
and then the burden more burden has been added to us’ (Male, Koinadugu, IDI-12)

27.
Salary uplift
 The salary uplift was a motivating factor for all the health workers and
changed the way they work in a positive way.
 However, there were different perceptions about the salary increase, with an
underlying theme of it being a positive step that was long overdue but not
commensurate with the role health workers play
‘Like I said earlier even with the last salary increment what they are paying us is not
enough to take care of our families, care for your children, provide feeding for them; like
what I am receiving is just barely enough to take care of my family so thinking about
having accommodation, medical bills, transportation, paying fees for my children’ (Male,
Kenema, IDI-5)
 There are some disparities among the different cadres of staff, with nurses
thinking that doctors have benefitted more from it.

28.
Experiences and perception of incentive
policies post FHCI
RAA
 Good initiative
 Focused on the job without any
distractions from being involved in
seconds jobs to augment their
income
 However, a number of concerns were
raised by health workers about the
RAA, mainly about the irregularity of
the payments
 ‘That was one policy I was really happy about
[…] But these monies are not forthcoming and
this has started discouraging staff posted in
remote areas’ (Male, Bonthe, IDI-2)
PBF
 Raised awareness amongst health workers
that they have to give improved quality of
service to service users over quantity of
service users treated
 Improvement in the health facilities
 It has also had a positive impact on record
keeping in health facilities a measuring
target in the PBF assessment.
 However it was also described as not
forthcoming
 ‘That was also a good motivation to encourage people
to work hard since the harder you work, they more
money you get. But again this is not forthcoming..’
(Male, Bonthe, IDI-2)

29.
Experiences and perception of incentive
policies during EVD
Positive
 Reported as valuable; it meant extra
income, which helped them cope
financially with the increased cost of
living during the outbreak
 Motivated some health workers to
work; on the other hand some
reported that they would have
worked regardless
 From a health facility manager’s point
of view it motivated HWs to come
back to work including the volunteers
not on payroll
Negative
 Not paid on time, which resulted in back
log and ultimately demotivating for
health workers
 Described as ‘pittance’ and not
commensurate with the risks involved
 Challenges with the verification process
 Payment on a mobile phone platform
also created challenges
 Took HWs away from the health facilities
to collect payment
 Some HWs did not own a mobile phone
 Poor mobile phone service coverage in
remote areas

30.
Overall perception of career post FHCI-
satisfaction
Motivating factors
 Being effective in their role
‘Before this time maternal death was on the rampage, but over the past 2 years
we’ve had none, we refer in time and we manage cases that are at our level the
one that we cannot manage we refer them appropriately’.(Male, Koinadugu, IDI-
11)
 Community Service
‘…. well what I like most is when I see a patient walking in the hospital and going
back with a smile and saying thank you going back home so I really love that and I
appreciate that very much’ (Female, Koinadugu, IDI-9)
 Financial incentives
‘I want to have a decent salary that will enable me to plan the lives of my children
so that they too can be in the position to be of use to their communities in the
future.’ (Male, Kenema, IDI-4

31.
Overall perception of career - satisfaction
 Improved working conditions
 Training opportunities
 Religion

32.
Motivating factors during the EVD
 Being of service was also captured as a motivational factor to
work during the EVD outbreak.
 A volunteer reported being motivated to work in an Ebola
treatment centre, in the hope of being absorbed onto payroll
 HWs felt that they needed to control the spread of the
disease in the district
“We just had to control this, otherwise if it spreads our district
and we don’t control it, it will spill over and a lot of health
workers will get involved” (IDI Bonthe, nurse, female)
33

33.
Demotivating factors –
pre and during EVD outbreak
Demotivating factors
Working conditions
Poor Management
Limited training opportunities and lack of
career progression
Limited financial incentives and benefits
Political interference
Relationship with community
Separation from family
Security (job and personal)
Tensions in the workplace
Poor retention of staff
Long working hours
Recruitment of staff
Challenges in rural postings
Pre-existing challenges faced by the
health sector that effected the EVD
response
Poor working conditions
Lack of IPC measures in place
Health workers ill-equipped to deal with
EVD/ health workers not trained
Lack of enablers
Low levels of motivation with health
workers
Relationships with the community
Mal distribution of the health workforce
Retention challenges

34.
Working Conditions - Urban vs rural
 Out of the 17 respondents that reported poor working conditions as a
demotivating factor, 11 were currently in rural postings.
Rural Urban
‘….. and also where we were having the clinic was a
community building. It was not conducive for the
work, the building was infested with rats, […]and we
were all living in that building […]Water was not
available […] For all the 5years I was there, I spent in
that dilapidated building; it’s heavily infested with
rats and lots of things. (Male, Kenema, IDI-4)
‘…..yes as we said sometimes we need materials
that we cannot get, materials yes drugs and supplies
or regular things that will make the working
environment convenient for us so that we will be
able to practice all what we are supposed to do; like
space is not adequate here’ (Female, Western Area,
IDI-20)
‘The terrain, the road network because if you don’t
have road worthy vehicle you cannot move […] and
the work load is so high because you have to visited
all PHUs’. (Female, Koinadugu, IDI-8)
‘…. the condition of the hospital was a little bit
better but there was still challenges [...] you have to
ensure that each and every patient receive
appropriate care, by then there were shortfalls for
the hospital administration …[….]….. these
challenges you know and that actually made work a
little bit difficult to us’(Male, Western Area, IDI-18)

35.
Poor management
 Professional relationships emerged as a demotivating factor
 Health workers felt that they should be involved in the decision making
processes that governed the management of the health facilities.
‘…and the councils yes they provide the funds but I think they should listen to
us the professionals instead of the support staff…[…]..Well its seems as if the
professionals are left behind, while those who went for administrative
coursesare at the top of the ladder whilst we are down so that one is not
encouraging; it is demotivating for us as professionals’ (Female, Kenema, IDI-
9)
36

36.
Limited training opportunities and lack of
career progression – Urban vs rural
 10 out of the 13 respondents that reported ‘limited training
opportunities and lack of career progression’ where in rural postings
‘…. I don’t have opportunity […] whenever there is an opportunity, to go for further course, we
are not remembered. Everything is staying in Freetown. […]If there is any provision it lies in
Freetown and they forget about us..[..] And we are here. Are we not part of the nurses, are we
not part of you people? Please try and think of us’ (Female, Bonthe, IDI-1)
‘ firstly in any profession you expect to grow.[…]you expect that government should help to build
your capacity [...]since we came out [as in graduated] I don’t think government has given us
anything to help us to motivate us in terms of building our capacity (Male, Koinadugu, IDI-12)
…. we are not much motivated you know like capacity building, I mean, I know scholarships
comes in this ministry they don’t look for the right people to give you know, and even when you
try by your own way to go and study they say we won’t give study leave, I mean these are like
demotivating things..’ (Male, Western Area), IDI-21

37.
Political interference – urban vs rural
 More urban respondents (5 out of 8) reported this as a
demotivating factor
‘Well now when a nurse goes out the way, you want to discipline that nurse, you get
order from above, whether you like it or not; order from above; interference, seniors are
not allowed to do their work, the chain of command is lacking, there is no stand of
control.’(Female, Kenema, IDI-9)
‘From superiors either professional like the doctors or even the permanent secretaries,
they interfere. I mean somebody who knows nothing about health care; they tell you
what to do […]And they are still doing it’ (Female, Western Area, IDI-23)
‘….even if you are doing the right thing you try to correct them you try to bring them to
what you want and they think that is not correct …[..]… phone calls, complimentary
cards, letters of threat and queries will come over to you and so some of us think about
that before taking actions that is why there are times when some people are let loose’
(Female, Western Area, IDI-14)
‘Some people may have misbehaved in the work place but because they are connected
they will go with the promotion they gave them you just see them promoted and you
don’t know how and you have been working hard.’ (Female, Western Area, IDI-18)

38.
Challenges specific to rural postings
 Specific constraints on the job, such as
 difficult terrain and bad roads
 poor communication
 delayed allowances or no allowances
 separation from their families.
 Posting policy states that duration of rural postings should be
two years.
 However, there are health workers who have negated the rural posting
process due to political interference.
 others who have defaulted from their rural postings without any disciplinary
action.
 Demotivating factor for those that stay in post.
39

39.
Coping strategies
Post Conflict
 Religion, patriotism and
improvising have served as
coping mechanisms
 The donor community has
also been helpful in
providing incentives for
those not on payroll
 Community hospitality
During EVD
 Training and the availability
of PPE made the health
workers more confident
 Being extra vigilant
 Religion
 Peer support
 Overall highlights the lack of
structured psychosocial
support systems
40

40.
Outstanding challenges for HRH
 Recruitment and deployment of staff
 Geographical imbalance in the spread
 HRH management challenges at central level
 No HRH unit at district level
 No HRIS system in place
 Ongoing payroll management issues
 Issues with sustainability and intuitional memory
 Incentives
 Financial vs non-financial
 Continued irregularities in payment of allowances

41.
Post Ebola reconstruction phase: lessons
 Health system should be rebuilt using evidence
based findings
 Coordination of efforts between development
partners and key stake holders
 National ownership

42.
ReBUILD is a 6 year £6million research project funded by the UK Department for International Development (DFID)
How much do HWs earn from different sources?
Drivers and consequences of the remuneration
structure of primary HWs
Maria Bertone
London School of Hygiene and Tropical Medicine & ReBUILD
maria.bertone@lshtm.ac.uk
Funded by

43.
Context and research questions
 Post-FHCI reforms to improve and align incentive package for HWs
 Salary increase
 PBF scheme with individual bonuses
 Remote allowance for those in rural posts.
 Still limited evidence on HWs actual earnings
 Formal allowances (incl. PBF), but also informal incomes
• How much do primary HWs earn?
• Income drivers at individual, facility and district level: who earns
which income and who earns more?
• What are HWs perspectives and views on their incomes?
• How do HWs use their incomes?

44.
Methods and sample

45.
Methods and sample (1)
 Survey of 266 primary HWs in 198 randomly selected PHUs in Bo,
Kenema and Moyamba
 CHOs, CHAs & nurses (SRNs+SECHNs), MCH Aides
 in-charge or highest in rank
 1 or 2 HWs per facility
 39 in-depth interview with a
sub-sample of HWs

46.
Methods and sample (2)
Cross-sectional
survey
Share of user fees
Salary
Remote Allowance
PBF (individual bonus)
Salary supplementations / top-ups
Per diems / DSA
Non-health income-generating
activities
Longitudinal
logbook
Gifts and payments from patients
Sale of drugs and items w/in facility
Private practice

47.
Gender Age
Type of
facility
Location District
male female CHC CHP MCHP urban rural Bo Kenema Moyamba Total
CHO 22 8 41.4 29 0 1 9 21 18 6 6 30
73% 27% 97% - 3% 30% 70% 60% 20% 20%
CHA+Nurse 32 44 40.8 39 32 5 24 52 23 33 20 76
42% 58% 51% 42% 7% 32% 68% 30% 44% 26%
MCH Aide 0 160 40.9 26 46 88 34 126 55 51 54 160
- 100% 16% 29% 55% 21% 79% 34% 32% 34%
Total 54 212 41 94 78 94 67 199 96 90 80 266
20% 80% 35% 30% 35% 25% 75% 36% 34% 30%
Methods and sample (3)

48.
Implementation of HRH reforms
“They [MoHS at central level] don’t even communicate with us. We are dealing with the
staff here, we know the staff movement. [...] But they say that they have the data there. But
sometimes they pay staff that are not even in remote areas” (KII – DHMT)
“I mean, [PBF] is good in theory, but when it comes nine
months later, I think it defeats the whole purpose” (KII –
DHTM).
“I heard many, many health workers, PHU staff, and DMOs talk about performance-based
financing. I've never heard anyone mention this remote area allowance”(KII – NGO).
“The real key issue is that with all of these policies and all of these strategies, none of them have been properly
operationalised and none of them have stayed around. Like, in 2002, there was a free health care policy
announced [...] and then it just didn’t happen. So free health care is announced again in 2010, and it’s like,
OK, it’s happening, but is that going to slowly start to fall apart? If PBF is announced, it’s like, oh it comes and
then it stops, you know.” (KII – NGO).
Remote allowance: 5%-8% of income of all HWs (Dec. 2012)  delayed and then stopped from Jan. 2013
Performance Based Financing: 11% of income of HWs (Sept. 2013)  payments received more than one
year later than services are performed
HWs incomes and income drivers

49.
60%
55%
63%
9%
9%
11%
19%
21%
15%
5%
7%
5%
3%
5%
2%
1,338,779 Le.
1,003,715 Le.
701,744 Le.
HWs incomes

50.
Who receives each income,
and earns more? (1)
 15% of the sample was not on payroll
 Interviews show that those trained or re-trained after 2010 were not paid the correct
amount or received no salary at all
 In-charges were more likely to receive:
 Salary (coef. 2.429 p.***)
 PBF bonus (coef. 1.342 p.***)
 Gifts from patients (coef. 1.005 p. **)
 and to carry out non-health activities (coef. 0.927 p. *)
 In-charges had
 higher PBF income (coef. 0.332 p**)
 and higher overall income (coef. 0.529 p.***)

51.
Who receives each income,
and earns more? (2)
 Younger HWs were
 less likely to get a salary (coef. -1.580 p.*)
 more likely to carry out non-health activities (coef. 0.700 p.**)
 HWs in urban areas were
 more likely to receive a salary (coef. 1.343 p.*)
 less likely to receive DSA and gifts from patients (coef.-1.151 p.***; coef.-0.761 p.**)
 No difference in total income between rural and urban
 No unfair advantage for those in urban areas
 but also no specific incentives for those in remote posts (as it was envisaged in the
incentive design)

52.
Who receives each income,
and earns more? (3)
 HWs in Kenema were more likely to
 receive PBF bonuses
 carry out non-health activities, compared to those in Bo and Moyamba
 Amount of income:
District salary PBF DSA Total income
Kenema 491,276 102,392 207,722 849,903
Bo 516,984 57,112 134,132 786,986
Moyamba 484,913 92,985 109,966 719,854

53.
HRH practices at district level
 Presence of NGOs (legacy of post-conflict context)
 Number and type of NGOs, and coverage of PHUs
 NGOs agendas and health priorities (e.g. humanitarian vs. development,
specific disease/service focus vs. broader HSS, etc.)
 Dynamics between NGOs and DHMTs
 Varying will, capacity and need to collaborate with DHMT
 Multilateral coordination vs. bilateral meetings (or none)
 Substantial asymmetry of power
 Re-orientation of local health priorities  difference in HRH
practices, which has an impact that extends all the way to individual
incomes.

54.
HWs views on their incomes

55.
HWs views on their incomes
 Income fragmentation as an issue
 Importance of non-financial features of incomes:
 Ease of access (cash vs. bank)
 Fairness and transparency
 Entitlement vs. windfall
 Delays in payment
 Transparency in sharing practices
 HWs said that they “manage”
“Well, if I gather everything together at the same time it helps [i.e. my income is enough],
but the money does not come together, it comes in little bits. So what I have at the
moment, I manage with it. I have no other way to do it” (CHA/nurse in Kenema).
“I have to manage my life with it [my income]” (MCH Aide in Moyamba)
“Well, it is not easy. You have to manage yourself” (CHA/nurse in Moyamba)

56.
HWs use of their incomes
 HWs took advantage of the different financial and non-financial
features of their incomes  spend different incomes differently
 Salary
 High and regular (“earmarked”) expenditures
 Received through bank account and not readily available
 Subject to family pressures
 DSAs, non-health activities, in-kind gifts from patients/communities
 Personal subsistence while in post+ emergency expenditures
 Readily available
 Unknown to family (“hidden”)
 DSAs and gifts shared with co-workers, especially in MCHPs
 PBF bonus
 Substantial amount which can be re-invested in non-health activities (e.g. business
such as buying palm oil, etc.)

57.
Background
Lessons & Recommendations

58.
Lessons & Recommendations (1)
 Improve management of official payments
 Salary payroll
 Remote allowance
 PBF bonuses
 Strengthen routine information system
 Decentralize HRH management
 Streamline and clarify allowances
 Improve transparency and regularity of payments
 Improve incentive packages for HWs
 Gather information on the entire remuneration of HWs, including
informal incomes, and include them in harmonization efforts (e.g. DSA)
 Reflect on the HWs perspective and uses of their incomes
 Incomes are not fully ‘fungible’

59.
Lessons & Recommendations (2)
 Sustain the long-term implementation of reforms beyond the
initial TA, through structural and institutional changes.
 Empower DHMTs
 Increased financial and human resources, better skills and capacity
 Widened decision-spaces
 Realistic and contextualized planning, budgeting and reporting under
DHMT lead
 Allow for open sharing of external agendas and budgets
 District ‘basket funds’?
 Reflect on post-crisis legacies
 Who does what and where? For how long? How is this going to influence
the system?

60.
This presentation is based on the papers:
Bertone MP, Witter S (2015), An exploration of the political economy dynamics shaping
health worker incentives in three districts in Sierra Leone. Social Science and Medicine,
141: 56-63.
Available at http://www.sciencedirect.com/science/article/pii/S0277953615300447
Bertone MP, Lagarde M, Sources, determinants and utilization of health workers’
revenues: evidence from Sierra Leone. Under review.
Bertone MP, Lagarde M, Witter S, Performance-Based Financing in the context of the
complex remuneration of health workers: findings from a mixed-method study in rural
Sierra Leone. Under review.
www.rebuildconsortium.com

61.
Acknowledgements
 Thanks to the key informants and the health workers who participated in this study
 to the enumerators’ team in Sierra Leone: Abdulrahman, Alimu, Christiana,
Fatmata, Edrissa, James, John, Michael, Precious, Sajallieu and Mr Bah,
and to David and Salim at the NGO Solthis for logistic support
 to Dr Mylene Lagarde and Prof. Sophie Witter for supervision and insights
 to the Fondation AEDES for supporting my PhD and ReBUILD Consortium for
funding fieldwork activities
www.fondation-aedes.org
F
O
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D
A
T
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N

62.
Overview of recommendations
arising from research
Funded by

63.
Overarching recommendations from research
(some now in progress….)
 The ReBUILD research emphasises the need to develop a coherent overall
package (financial and non-financial), focussing on implementation and
follow-through, with good alignment of government and partners.
 Capacity for effective human resource management at MoHS and District
Health Management Team level is needed to reduce dependence on
external technical support
 Donors need to engage long term – building institutional capacity to carry
forward stronger systems
 Also to sustain the momentum for reform and financing of increased HR
commitments
 Need to address priority shortages of staff, also proving them with key
inputs needed to deliver care (equipment, drugs etc.)

64.
Overarching recommendations (2)
 The recruitment process for health workers is too centralised, allowing local
managers no role in staff selection and performance management. The Health
Service Commission should address this.
 Decentralisation of the process might also reduce the time which is currently taken to engage new
staff, something which causes demotivation and attrition.
 A full package of measures should be introduced to address the rural/urban divide
for health staff, beyond the currently erratic RAA to include:
 specific tours of duty (e.g. 2 years), which are respected;
 preferential training access for those working in rural areas; and
 provision of housing to facilities (especially for female staff)
 more local training and recruitment
 For all human resource for health (HRH) functions, a well functioning routine HR
information system is critical. This has been planned for some years but not
delivered.

65.
Revising the remuneration package
 The PBF scheme should be reformed so that payments are regular, 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.
 Especially important for staff who are not on payroll and community agents
 The remote area allowance should be reviewed and reintroduced 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.
 Communication – let staff know what is happening with it!
 Greater involvement in its design would also ensure that health workers
understand how it is meant to operate.

66.
Remuneration (2)
 Payroll management needs improving to reduce delays in getting on payroll.
 Volunteers are coming back in (as per pre-FHCI)
 Systemic problems in paying financial top-ups should be addressed. The risk
allowance during the Ebola outbreak and response was the most recent example
of an allowance which was not received reliably by health staff, causing frustration
and demotivation.
 NGOs’ activities to support health workers should be better aligned and
coordination should be reinforced.
 this will avoid disparities between cadres and districts, such as, for example, differences in the level
of DSA payments and in the support provided to services related to PBF (which in turn increases PBF
bonuses in some districts).

67.
Remuneration (3)
NGO and donors’ exit strategies and the
removal of incentives post-Ebola should
be coordinated and managed in order to
avoid demotivation, and further
exacerbate the mal-distribution of the
health workforce, with remote and hard
to reach areas being at a disadvantage.
 Including hand-over and capacity
building to enable systems to be
managed longer term

68.
Strengthening career pathways
 Routes into the medical profession
for local students should be
encouraged as it is likely that these
staff, especially if mid-level, will more
easily be retained in rural areas.
 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
Health Workers in Sierra Leone).
 Direct entry into midwifery training
should be considered to address
severe shortfalls in this cadre.

69.
Continuing professional development
 Staff report improved training opportunities since the FHCI;
however, concerns about skill levels need also to be taken
seriously. This is an area where systematic evidence is lacking.
 Regional disparities in access to training should be addressed,
reversing the bias, so that those serving in rural areas have
higher chances of training
 Given the additional domestic responsibilities of women,
supportive measures should be put in place to support them
in accessing and taking up training opportunities
 Meaningful CPD activities should be linked in as mandatory to
career progression, based on individual and facility needs

70.
Thank you
On behalf of ReBUILD consortium
 Institute for International Health and Development (IIHD), Queen
Margaret University, UK
 Liverpool school of Tropical Medicine (UK)
 College of Medicine and Allied Health Sciences (CoMAHS), Sierra
Leone
 Biomedical Training and Research Institute (BRTI), Zimbabwe
 Makerere University School of Public Health (MUSPH), Uganda
 Cambodia Development Research Institute (CDRI)
www.rebuildconsortium.com
71

71.
Thanks also to all the ReBUILD team in Sierra
Leone
 Dr Joseph Edem-Hotah
 Dr Mohamed Samai
 Professor Sophie Witter
 Dr Joanna Raven
 Dr Haja Ramatulai Wurie
 Maria Paola Bertone
 Mr Rogers Amara
 Margaret Mannah
 Yatta Kosia
 Mr Amara Katta 72

72.
Afternoon session
Chair: Dr SAS Kargbo
Mr Emile Koroma (MOHS)
 Current priorities and debates for reform
within the D-HRH and HRH WG and
evidence needs
Discussion and panel session
 The way forward – evidence needs and
use to support a health workforce for all

73.
The Way Forward:
Discussion and panel session
 What are the HRH evidence needs in
Sierra Leone today?
 How can these best be generated,
communicated and used in support of a
health workforce for all?

74.
Thank you
Evidence for supporting a health workforce
for all in Sierra Leone
College of Medicine and Allied Health Sciences