Research for stronger health systems during and after crisis

Sierra Leone

Related Resources:

Find more resources relating to Sierra Leone


ReBUILD's work in Sierra Leone was led by the College of Medicine and Allied Health Sciences in Freetown.

The research followed ReBUILD’s core themes of health financing and the effect on poor households’ access to health services, and of policies on human resources for health and the incentive environment for health workers.

However the outbreak of Ebola Virus Disease in 2014-15 also shaped ReBUILD’s activities in Sierra Leone. An additional research project was conducted on the effects of the Ebola outbreak on health workers and the health system, to identify lessons for future health system reconstruction. The ReBUILD partners were also actively working with policy and implementing organisations both within Sierra Leone and internationally to ensure that relevant research findings have been accessible to those involved in maintaining health services during the outbreak and in the rebuilding of the health system during recovery from the outbreak.

ReBUILD's work in Sierra Leone also includes a further line of research being conducted by ReBUILD's Affiliate partners at the London School of Hygiene and Tropical Medicine, into health workers' incentives, remuneration and accountability.

Health financing and the effects on poor households

Sierra Leone has a particularly high share of out-of-pocket expenditure in relation to total health spending at around 70%. The NHSSP notes that approximately 50% of the population is excluded from health services by even modest fees. A package of free services for pregnant and lactating women and children under 5 was introduced by April 2010. This package was a Government initiative to address the financial burden placed on households because of payments for healthcare and commodities. Salary increases for health workers were also introduced and these have been supported with financing from donors. ReBUILD’s work aligned with this drive to improve access to healthcare, and the aim of this work was to encourage the use of research evidence to reduce mortality and morbidity amongst the population, particularly in women and children.

Our research focused on understanding the impact of the free healthcare package, particularly in relation to the poorest households and gendered expenditure. Official and unofficial fees are a recognised problem in Sierra Leone and it was not clear how they would be affected by the free package policy. We also explored how poor households negotiate the plural health system in which private providers, non-governmental organisations and herbalists are frequently accessed.

A phase two project also considered the impact of performance-based financing in the state.

The incentive environment and experiences of health workers, post-conflict and during the Ebola outbreak.

We studied the effects of policies on health worker incentives to better understand how we can create incentive environments that support access to rational and equitable health services. This was particularly important in the light of proposed results and performance-based incentives which were to be introduced. Our wide-ranging research on health worker experiences and motivation conducted prior to the Ebola outbreak has been complemented by additional research on the effects of the Ebola outbreak on health workers and the health system. Findings from this work are being used to inform current strategies and implementation of policies on human resources for health in the long-term rebuilding of the health system during recovery from the Ebola outbreak.

Using community health workers in fragile and conflict-affected settings

Phase two of ReBUILD included a project on using community health workers in fragile and conflict-affected settings, with Sierra Leone as the main focus. Community health workers (CHW) play an important role in healthcare delivery, and this study aimed to identify how the community CHW cadre might be better supported to play an effective and long-term role in the broader health system in fragile contexts.

Haja Wurie of ReBUILD and College of Medicine and Allied Health Sciences talks on a study to understand how to better support community health workers in Sierra Leone.




Read an update on our work in Sierra Leone from August 2013