Health Workers’ Remuneration, Incentives and Accountability in Sierra Leone
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This research project was led by the London School of Hygiene and Tropical Medicine, and funded by ReBUILD's responsive fund.
Human resources for health are recognized to represent an essential component for the functioning of health systems, however, throughout sub-Saharan Africa, health workers (HWs) remain demotivated and underperforming. Devising the right incentive package for HWs is essential to improving their performance, but in many settings it is unclear what financial incentives are actually offered to HWs, because of the existence of a understudied combination of payment sources (e.g., salaries, governmental allowances, user fees, external agencies payments, private practice, informal incomes, non-health activities). Income fragmentation might be particularly relevant in post-conflict countries, where the relative weakness of the government and the presence of multiple external actors set the scene for multiple agendas, priorities and strategies. Following a decade of armed conflict and social and economic unrest, Sierra Leone has been rebuilding its health system since 2002. Despite the recent efforts to align of harmonization and alignment of HWs remuneration policies, Sierra Leone is no exception and HWs’ earnings remain fragmented between different sources and payment modalities. However, little quantitative data exist on the actual remuneration structure of HWs and its effects, in Sierra Leone as elsewhere.
Partially funded under a ReBUILD Responsive Call, this research explored the nature and consequences of the fact that public Health Workers in Sierra Leone receive remuneration from multiple sources, by (i) quantifying the overall HWs remuneration and its different components, (ii) investigating the links between incomes and activities carried out by HWs as well as (upward) accountability relations, (iii) reflecting on the district-level dynamics that shape the HWs remuneration structure. Extensive fieldwork was carried out in three districts of Sierra Leone (Bo, Kenema, Moyamba) between June 2013 and May 2014.
This research project contributed significantly to ReBUILD's wider research on health worker incentives, and has contributed to the policy debate in Sierra Leone, and in other post-conflict settings. First, quantifying the remuneration structure of HWs, including those components that are often undetected, informed national discussions on HWs remuneration and incentives. Second, understanding the consequences of complex remuneration structure at the health system-level helped shed light on broader issues particularly relevant in post-conflict settings, such as the stewardship capacity of the government. Important lessons and good practices were identified for the government of Sierra Leone, as well as for NGOs and donors.