ReBUILD’s human resources for health research

Meeting28th January 2016

Hill Valley Hotel, Freetown

Evidence for supporting a health workforce for all in Sierra Leone

College of Medicine and Allied Health Sciences

Morning sessions Welcome and opening remarks Presentations:

Introduction and overview of ReBUILD and its HRH research Evolution of HRH policies

Organisational statementsTea break

Presentations of ReBUILD research Experiences of incentive policies for health workers Remuneration structure of primary healthcare workers Summary of policy recommendations

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

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

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

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?

Summary of research toolsResearch 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 phase39 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

Research sites Western Area (Urban/Rural) Kenema (Eastern Region) Bonthe (Southern Region) Koinadugu (Northern Region)

Also affiliate project in Bo, Kenema and Moyamba

Research outputsOnline 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.

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

ReBUILD is a 6 year £6million research project funded by the UK Department for International Development (DFID)

Windows of opportunitiesLessons learned on policy-making from post-

conflict Sierra Leone (2002-2012)

Maria BertoneLondon School of Hygiene and Tropical Medicine & ReBUILD

maria.bertone@lshtm.ac.uk

Funded by

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 Leone2002-2012

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)

Three phases of HRH policy-making

Definition of allo

wances

2009 2010 201220112006 2007 2008

FHCI -

Announcement

FHCI -

Launch

National Health

Policy (2

002)

HRH Development P

lan 2004-

2008

HRH Policy

2006

HRH Policy (2

012) &

HRH Strategic

Plan 2012-

2016

Payroll c

leaning, fast-

track

recruitm

ent & sa

lary

increase

Perform

ance-based Financin

g

Sancti

on Framework

Remote Allowance

Review of th

e Scheme of

Servi

ce

Attendance Monito

ring Sy

stem

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

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 contextThe 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).

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)

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

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

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

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.

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

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

Haja Ramatulai WurieResearch 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

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

Effect of FHCI HRH reforms

Staff sanction framework - Rates of reported unauthorised absenteeism, Sierra Leone health workers, 2011-14-1%

4%

9%

14%

Unau

thor

ised

Ab

sent

eeis

m

2005 2006 2007 2008 2009 2010 20110

0.010.020.030.040.050.060.07

Medical and nursing staff per population, Sierra Leone

Medical staffNursing staff

Heal

th p

rofe

ssio

nal p

er

1000

in th

e po

pula

tion

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

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)

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)

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.

Experiences and perception of incentive policies post FHCIRAA 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)

Experiences and perception of incentive policies during EVDPositive 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

Overall perception of career post FHCI- satisfactionMotivating 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

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

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

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

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)

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

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

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)

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

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

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

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

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 BertoneLondon School of Hygiene and Tropical Medicine & ReBUILD

maria.bertone@lshtm.ac.uk

Funded by

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?

Methods and sample

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

Methods and sample (2)

Cross-sectional survey

Share of user fees

Salary

Remote Allowance

PBF (individual bonus)

Salary supplementations / top-ups

Per diems / DSANon-health income-generating activities

Longitudinal logbook

Gifts and payments from patientsSale of drugs and items w/in facilityPrivate practice

  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)

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. 2013Performance 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

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

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.***)

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)

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

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.

HWs views on their incomes

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)

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.)

Background

Lessons & Recommendations

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’

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?

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

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

FONDATION

Overview of recommendations arising from research

Funded by

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.)

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.

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.

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).

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

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.

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

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

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

Afternoon sessionChair: 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

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?

Thank you

Evidence for supporting a health workforce for all in Sierra Leone

College of Medicine and Allied Health Sciences