Table 4 Details related to UHWs references in the texts included in this scoping review

1

GoSL, MoHS 2016, Human Resources for Health Summit, 2–3 June 2016

Freetown, Sierra Leone

Gov policy/Min of Health & Sanitation report

Substantial references of UHW in detail

"Removing [ghost] health workers from the payroll should result in an annual saving of approx. $2 million (10% of the MOHS wage bill), freeing up fiscal space to absorb volunteers into the health workforce".

…some transfer decisions can be made at the district level and “informal recruitment” of unemployed health workers volunteering takes place at the facility level without prior knowledge at the national level. Workforce data management was also described as a priority challenge, with iHRIS currently being introduced and institutionalized to redress the situation.

2

GoSL, MoHS 2016, Human Resources for Health Country Profile Sierra Leone

Gov policy/Min of Health & Sanitation report

Substantial references of UHW in detail

“…the overproduction of SECHNs has led to a significant rate of unemployment for these nurses: roughly 2,000 unsalaried, licensed SECHNs were found to be practicing in government facilities… The coexistence of SRN shortages with SECHN unemployment highlights the need for better coordination of pre-service training plans with MoHS health worker production needs.”

A MoHS payroll audit suggests as many as 9,120 UHWs are active in Sierra Leone’s government health facilities, out of 19,030 public sector health workers. Of the 9,120 UHWs, 3,690 (40%) serve as health professional providing patient services, primarily in the lower-skilled cadres.

3

GoSL, MoHS 2016, Human Resources for Health Strategy 2017–2021

Gov policy/Min of Health & Sanitation report

Policy proposal re UHWs in detail

“Roughly half of health workers active in government facilities are unsalaried and, hence, not part of the formal health workforce – making it difficult to supervise and regulate these workers.”

In ref to UHW: “The HRH strategy should thus include a clear policy statement to address these unemployed, and thus unregulated, health workers”… ”[HW] production often exceeds the government’s absorption capacity – particularly for lower cadre health workers. This has resulted in over 3,600 unsalaried clinical health workers providing patient services in government facilities despite not being part of the formal MoHS workforce.”

… no progress on “establishment of a nationally coordinated pre-service training plan since 2011. As a result, production often exceeds the government’s absorption capacity – particularly for lower cadre health workers” … ”professional [health training institutions] regulatory bodies remain under-resourced, meaning some [medical training] programmes continue to operate without accreditation, and the licensing process is challenging to enforce and monitor.”

“Cost estimate: USD 6 million over 5 years on salaries resulting from the absorption of unsalaried health workers in critical cadres…

Develop and implement a plan for absorption of critical unsalaried workers, i.e. workers trained as SRNs, midwives, or CHOs, and a policy on remaining unsalaried workers – including relevant management and monitoring procedures for enforcement”

[2016 Payroll verification]

“resulted in a cleaned payroll dataset of all MoHS staff, a comprehensive database of the existing health workforce – including the unsalaried workforce – and updated guidelines and standards of practice to streamline and maintain payroll”

4

GoSL, MoHS 2017, Sierra Leone Service Availability and Readiness Assessment [SARA]

Gov policy/Min of Health & Sanitation report

Substantial references of UHW in detail

"There was a total of 323 general and specialist doctors in the country. It is notable that 35% were not formally employed. They offered their services either on a part-time basis, paid by the facility management or a nongovernmental agency, or on a volunteer basis."

5

GoSL, MoHS 2021, National Health Policy 2021–2025

Gov policy/Min of Health & Sanitation report

Short reference

“Despite the introduction of the FHCI in 2010 to reduce the financial burden of accessing care by the vulnerable groups, the cost of care is still considered to be out of the financial reach of the majority of the population, posing financial risk to them. It is estimated that households out of pocket expenditures contribute 61% of total health expenditure in Sierra Leone (NHA 2018 study) one of the highest in sub-Saharan Africa.”

“The Directorate of Human Resources for Health (DHRH) developed a national HRH Policy and an HRH Strategy to address the challenges affecting healthcare workers in Sierra Leone from 2017–2021. The HRH Strategy 2017–2021 provides a framework to guide investments and activities to achieve the vision, goal and objectives set forth in the HRH Policy 2017–2021.”

6

GoSL, MoHS 2021, National Health Sector Strategic Plan 2021–2025

Gov policy/Min of Health & Sanitation report

Policy proposal lacks detail re UHWs

Reference to Out-of-Pocket Expenditure.

“An annual multi-stakeholder HRH forum for medical training institutions and other stakeholders may be held to assess intake numbers and priority areas, to match the sector needs. This may include both pre-service and in-service training to upgrade competencies of certain health workers to those most needed, such as more midwives, registered nurses, medical doctors, and biomedical scientists/technicians, among others, focusing on quantity and quality.”

“It was estimated that there are around 20,000 health workers in Sierra Leone who work in a variety of cadres; approximately 50% are volunteers and not on the government payroll” [2016 data].

“Health workforce performance management and accountability may be strengthened, based on a comprehensive review of staffing norms, making use as needed of the Workload Indicators of Staffing Needs (WISN). A facility-by-facility health workforce gap analysis may be conducted annually to inform HRH recruitment and deployment.”

7

Bakker et al. 2021, Barriers to increase surgical productivity in Sierra Leone: a qualitative study

Peer reviewed article

Refs to UHW waiting for inclusion on payroll and upskilled surgical providers whose salaries not adjusted upward to reflect new job/responsibilities

Financial barriers observed for surgery, both at patients demand side and hospitals provision side. + Gen observation that FHCI care is not always free

FHCI patients pose financial pressure on facilities; required supplies from government are insufficient. Costs passed on to patients, decreasing access to surgery

“Informal system of care providers exists within and outside of public health facilities.”

“Informal/unlicenced ‘mushroom’ clinics in community delay necessary care.”

“Financial incentives to not record surgical activities in hospital logbooks”: under-registration of surgeries

8

Bertone and Witter 2015, An exploration of the political economy dynamics shaping health worker incentives in three districts in Sierra Leone

Peer reviewed article

HRH focus, ref to 15% of HW not on payroll during 2013 research

Access to drugs = powerful financial incentive for health workers if there is room for misappropriation and informal sale

9

Bertone and Lagarde 2016, Sources, determinants and utilization of health workers’ revenues: evidence from Sierra Leone

Peer reviewed article

In-depth log-book data from 266 HWs on their sources of income incl. informal. …odds of receiving salary are 11 x larger for in-charges [i.e. the facility managers] compared to staff workers, less for MCHPs than CHCs

In-charges or CHOs more likely to receive gifts from patients: “the fact that 74% of workers declared to be receiving [gifts] and their estimate at 3–5% of total revenues seems to be reliable with reference to another aspect of the relation between HWs and patients/communities”

“…odds of earning income from selling drugs are almost 20 times larger for CHOs compared to CHAs/nurses and MCH Aides”

Among income sources for HW is private practice; more common among higher cadres such as doctors, CHOs

10

Bertone, Lagarde and Witter 2016, Performance-based financing in the context of the complex remuneration of health workers: findings from a mixed-method study in rural Sierra Leone

Peer reviewed article

Short ref to PBF payments being perceived as salary/payment for unsalaried HWs

"In some cases, health workers posted immediately after training were given individual [PBF] bonuses despite not being eligible for it as not working in facility when the bonus was accrued. This practice was justified by the fact that they were not yet on payroll and would have little alternative financial means to support themselves."

11

Brooks and Herrick 2019, Bringing relational comparison into development studies: Global health volunteers’ experiences of Sierra Leone.

Peer reviewed article

Substantial refs to UHW in context of international medical volunteers experiencing tertiary hospital in Freetown

“An informal system of nursing care and Medication distribution had developed. Unsalaried volunteer nurses drew an income from patients”

“Many Sierra Leonean nurses went unpaid and sold medicines and supplies ‘from their handbags’.”

Shortcomings re staff, too many UHWs, lack of supplies, electricity, water- unrealistic to expect ‘teaching hospital quality services’

12

Dorwie and Pacquiao 2014, Practices of Traditional Birth Attendants in Sierra Leone and Perceptions by Mothers and Health Professionals Familiar with Their Care

Peer reviewed article

Refs to TBAs accepting any kind of payment whereas health practitioners require upfront fees [pregnant women entitled to FCHI free care]

“TBAs [Traditional Birth Attendants] are affordable care providers who accept any form of payment (cash, goods, or services). Unlike HPs who require standardized, upfront fees, TBAs give services first, and families can pay later based on what they can afford.”

[UHW lacking trust in health system themselves] “One physician commented that we have to look at the underlying problem. People access care only when they are in dire need; the doctors are greedy and make it difficult for the poor and the needy. The country is full of corruption, one works and expects to get paid at the end of the month, but this is not the case.”

This paper focuses on TBAs and highlights some women’s preference to receive TBA care, as it is perceived to be cheaper and they offer flexible payment options- this demonstrates that pregnant women may opt seek potentially unsafe TBA care if healthcare workers are found to charge for care that should be free.

“All groups of participants disdained TBAs motivated by money, placing the mother and baby in jeopardy. Each group of participants described several incidents when mothers suffered complications (e.g., bleeding, sepsis, rupture or prolapsed of the uterus, fetal and maternal death) because of failure of TBAs to make timely referral to HPs. HPs gave examples of unsafe TBA practices as forcing labor, unsanitary conditions, condoning superstitious and unhealthy cultural practices, use of toxic chemicals (kerosene), dangerous remedies (papaya leaves, animal dung), witchcraft.”

13

Elston et al. 2020, Maternal health after Ebola: unmet needs and barriers to healthcare in rural Sierra Leone

Peer reviewed article

Barriers; cost* + inaccessibility, “delayed/prevented 90% rural, 59% urban pregnant women from receiving healthcare [n = 608].” *Cost = Lack of money for either paying for a consultation with a healthcare worker (HCW).

Refs to pregnant women having to buy medicines from HWs.

Also: Ref to ‘informal skilled care being available to urban women, in form off ‘off-duty HWs’’.

Additional maternal care seeking barrier: concerns about being treated disrespectfully by HCWs. Also: additional barriers including lack of medications and HCW absences.

“Women expressed mistrust of HCWs primarily due to payments for ‘free’ healthcare. Despite preference for biomedical care, 48% rural and 31% urban women gave birth outside of a health facility.” Also: HCWs described lack of pay, poor conditions precluding provision of quality care.

“Participants explained a preference for delivering at home with the assistance of a local off-duty nurse, only seeking hospital care when complications were beyond their skills.”

14

Enria et al. 2021, Bringing the social into vaccination research: Community-led ethnography and trust building in immunization programs in Sierra Leone

Peer reviewed article

Several mentions of UHWs and coping strategies which emerge as contributing to lack of trust in gov health facilities [during Ebola vaccine trial research]

Researchers, who are CHWs uncover “structural issues that underpin mistrust in the health sector”. CHWs recommend the provision of stipends for volunteer health workers [as full time UHW receive less than part-time, semi-trained CHWs]

“…frequent drug stockouts which led to health staff having to ask patients to buy their own, or the fact that nurses were volunteers and at times had to supplement their income by ‘selling’ vaccination cards.”

Respectful, two-way dialogue as step towards restoring trust: both community + HWs “concerns, anxieties and limitations discussed”, e.g. “fact that health workers are often not paid was useful for understanding the challenges to delivering [health] services”

15

Frankfurther 2019, Conjuring Biosecurity in the Post-Ebola Kissi Triangle: The Magic of Paperwork in a Frontier Clinic

Peer reviewed article

Focus on one remote clinician, expected to “given great autonomy to create auxiliary staffing systems” and “define informal payment schemes”

“Clinicians like Tamba are left to make do by crafting their own informal payment plans and contracting with independent pharmaceutical suppliers to keep clinics stocked”

16

Herrick and Brooks 2018, The Binds of Global Health Partnership: Working out Working Together in Sierra Leone

Peer reviewed article

Brief mention of UHW

“Many of Connaught’s nurses worked as unpaid volunteers often making their living by charging patients informal fees for goods and services [in addition to the formal fees of the hospital]”

17

Jalloh et al. 2022, Association of community engagement with vaccination confidence and uptake: A cross-sectional survey in Sierra Leone

Peer reviewed article

Brief mention of UHW

Research suggests caregivers expect to pay for their child’s vaccines despite FHCI. Research connects charging for care to UHWs

18

McPake et al. 2013, Removing financial barriers to access reproductive, maternal and newborn health services: the challenges and policy implications for human resources for health.

Peer reviewed article

Brief mention of UHWs, pointing out that in 2012, few UHWs left, probably due to lack of user fee income

19

Miller et al. 2018, Community health workers during the Ebola outbreak in Guinea, Liberia, and Sierra Leone

Peer reviewed article

Brief mention in CHW context. Re debating option of paying stipends through gov payroll -point made that even those on payroll don’t all receive salary

20

Navarayan et al. 2018,“If I had known, I would have applied”: poor communication, job dissatisfaction, and attrition of rural health workers in Sierra Leone.

Peer reviewed article

Rural HW focus, lack of salary emphasised, lack of info about procedures, incl ‘how to get on to the payroll’

Rural HW attrition: 63% of SL’s population is rural, only 33% of HWs work at rural PHU; study emphasises rural disadvantage re HR policies, incl. payroll related for UHWs

21

Nyhus and Kamara 2017, Quality improvement in emergency service delivery: Assessment of knowledge and skills amongst emergency nurses at Connaught Hospital, Sierra Leone

Peer reviewed article

Emergency nursing assessment in tertiary hospital; nurses note low/no salary, bureaucratic challenges re career opportunities

“Unofficial out-of-pocket payments and a high percentage of the nurses not receiving salary [71%] must be addressed”

Challenges re implementing triage protocol at referral hospital A&E, due to “out-of-pocket payment considerations” from other hospital wards

22

Oyerinde et al. 2011, The status of maternal and newborn care services in Sierra Leone 8 years after ceasefire

Peer reviewed article

Study notes “unemployed trained health workers [“volunteers”] in public health facilities. They were paid for services by private arrangements with patients and their relatives.”

Despite “national policy states that MCH services are free” pregnant women and sick children paid fees. Chargers “varied widely between facilities and were so unpredictable or arbitrary that patients and their families could not anticipate their OOP expenditure”

23

Pieterse and Lodge 2015, When free healthcare is not free. Corruption and mistrust in Sierra Leone’s primary healthcare system immediately prior to the Ebola outbreak

Peer reviewed article

Study notes encounters w UHWs, contains UHW interviews, interviews + FGD w FHCI target group healthcare users, who report charging for care

Study notes “charging for free care” allegations during 24 out of 35 FDG

Study notes “charging for free care” allegations during 24 out of 35 FDG; including charges for medicine, vaccine or ante-natal care cards

High levels of mistrust of HWs noted among pregnant women, mothers w < 5 children [FHCI target groups], aware that supposed free care is not being delivered. Mistrust in HWs were thought to have led to evasive actions by some EVD patients and patients’ families, whereby treatment was delayed or not sought and the spread of EVD exacerbated

Study specifically examined ‘accountability promoting interventions’ most of which failed to reduce informal charging, some HW behaviour did improve

24

Squire et al. 2017, The Ebola outbreak and staffing in public health facilities in rural Sierra Leone: who is left to do the job?

Peer reviewed article

Study on staff shortages in Kailahun District: of 805 recommended medical staff [minimum requirement in 82 PHUs], deficits of 539 [67%] pre-Ebola, 528 [65%] during the Ebola outbreak and 501 [62%] post-Ebola existed

“the issue of non-registered volunteer staff is of concern. If they are not captured by information systems, such staff may … be left out when facility requirements for personal protective equipment are being considered. Volunteers will thus be more susceptible to both acquiring and transmitting infectious diseases to co-workers, patients and the community at large.”

25

Squire et al. 2020, Staffing in public health facilities after the Ebola outbreak in rural Sierra Leone: How much has changed?

Peer reviewed article

Short study on staff shortages in Kailahun district, 3 years post-Ebola; noting that “nothing has changed”

“…ensure that at the subnational level there are sufficient numbers of candidates from the cadres… These steps should be preceded by a national census of HCWs to identify trained but currently unemployed individuals who could be absorbed into the public services”

“due to budgetary limitations on paying salaries, many health care workers serve as volunteers in health facilities and are not on a regular payroll”

“HCWs not on the payroll do not get paid a salary. Other incentives, such as performance-based financing and stipends for training and national campaigns, may help. These incentives, however, do not constitute a living wage.”

26

Tengbe et al. 2023, Psychosocial impact of COVID-19 pandemic on front-line healthcare workers in Sierra Leone: an explorative qualitative study

[improvements need to successfully respond to future epidemics] “Improving conditions of service, availability of essential medications and supplies, the recruitment of volunteer HCWs not on the government payroll”

27

Treacy, Bolkan, Sagbakken 2018, Distance, accessibility and costs. Decision making during childbirth in rural Sierra Leone: A qualitative study

Peer reviewed article

Vague ref to charging for care, couched as ‘appreciation’ for HW who are paid late and if at all, very little’

Cost as barrier to care seeking during childbirth

28

Vernooij, Koker, Street 2022, Responsibility, repair and care in Sierra Leone’s health system

Peer reviewed article

Ethnographic study illustrating how to “make the [hospital] system work, for the sake of the patients”

“…scholars have written about the informal payments underpinning transactions in the Connaught Hospital, reporting that unsalaried staff [routinely referred to as ‘volunteers’] draw an income from patients by selling medicines and services”

“The breakdown in government supply systems created a gap in service availability which was patched by health workers, who established a quasi-private testing service within the hospital and took on the responsibility of procuring materials. [It happens at] every site of medical testing in the hospital, ranging from the triage [where nurses sold glucose tests] to the laboratory and radiology department.”

29

Willot et al. 2021, Staff recognition and its importance for surgical service delivery: a qualitative study in Freetown, Sierra Leone

Peer reviewed article

Study to understand barriers to surgical care from a variety of perspectives, to recommend interventions to improve access and quality of care

Patients: “many health workers [are] unapproachable and uncaring, particularly towards poorer patients who are unable or unwilling to pay staff extra in the form of informal payments for their care”

Low morale leading to poor care: “Low morale is exacerbated by perceptions of a lack of recognition of their work by superiors and by the system itself. Our research suggests that nurses do not feel valued by the management of the hospital or by the MoHS.”

30

Wilson et al. 2022, Challenges and solutions to providing surgery in Sierra Leone hospitals: a qualitative analysis of surgical provider perspectives.

Peer reviewed article

Focus on surgical capacity, which is hampered by heavy reliance on UHWs

High levels of UHW absenteeism: “volunteers have no official compensation structure, they are difficult to hold accountable for the work they perform”

Large reduction in surgical capacity by only conducting surgery when sufficient staff: “One provider, noting that support staff [many UHWs] tended to leave by the afternoon, scheduled major surgical cases in the morning”

31

Witter et al. 2015, The free health care initiative: how has it affected health workers in Sierra Leone?

Peer reviewed article

Predominantly focused on pre-FHCI HRH conditions, highlights UHW “volunteers” who are subsequently added to payroll

Study connects payment for fees and lack up uptake by highlighting impact of fee removal “people who were afraid in the former days to come to the hospital because maybe they were not having money, they think they will be charged and so on, are coming in hundreds”

Study pinpoints lack of long-term HRH solutions: “long-standing issues, such as improving and decentralizing the recruitment, deployment and management of HRH still unresolved”

32

Amnesty International 2009, Out of Reach: The Cost of Maternal Health in Sierra Leone

Research report

Pre-FHCI report exposing barriers to healthcare access, some of it related to UHW and low pay of all HWs

The Anti-Corruption Commission [2008] “recognized that conditions of service are poor and need to be improved but also found that staff at all levels were unilaterally charging revenue and not reporting it”

The report highlights that donated medical supplies are for sale in markets, while health facilities are out of stock, or patients pay for donated medicines and supplies

The lack of HW pay and poor working conditions has led to “widespread corruption and arbitrary charges… [impacting] quality and availability of health care. The fear of costs, and the refusal of some health workers to treat women without payment even in an emergency, leads to deadly delays in the decision to seek or receive care”

“Poor inventory control management, together with poor accountability and mismanagement of drugs and supplies, have been identified as problems”

33

Bertone and Witter 2013: The development of HRH policy in Sierra Leone, 2002–2012 – report on key informant interviews

Report published by Rebuild Consortium

Refs to UHWs pre-FHCI. Also the 2011 planned Health Service Commission [HSC], which is still not functioning

[Pre FHCI] money was a barrier for women and children to access the health service delivery

“HWs may e.g. refuse to work in rural areas as they may not be able earn additional income from private practice or other sources”

34

Govindaraj R, Herbst CH, editors. Strengthening post-Ebola health systems: from response to resilience in Guinea, Liberia, and Sierra Leone

World Bank report

2018 review; UHW % of total health workforce: 48% in SL, 44% in Liberia and 39% in Guinea.

Report presents HRH statistics warning it uses formal payroll data to calculate density, but cautions that stats exclude informal HRH

35

Witter et al. 2016, The Sierra Leone Free Health Care Initiative [FHCI]: process and effectiveness review

Report published by Rebuild Consortium

Extensive [300 page] report that includes finance analysis and highlights role of UHWs in health system around 2015

“Despite much probing, it was also impossible to understand how these volunteers survived financially: some did get a share of the PBF and some did not. They all denied charging under the counter, although one facility did state that patients gave fees to volunteers voluntarily”

”

“In some areas visited… the volunteers are reported to outnumber paid staff” … “This causes difficulties for staff management and accountability”

Research among HW showed that non-salary income such as private practice income, PBF, patient gifts, per diems etc.

However, the [2015] situation has deteriorated since [FHCI introduction] “the recruitment drive has not continued and many staff who joined in recent years are not on payroll. Some new facilities have also opened, which stretches staffing more thinly.”

Survey data from 141 PHUs shows that they spent one-third of income [PBF and cost recovery] “on volunteer incentives and community outreach, highlighting the role of non-formal staff at PHU level” “PBF payments were reported to be motivating, when received, although many reported a long delay since they had last received any PBF. PBF is particularly important to motivate the unsalaried staff”

36

Wurie et al. 2014, Staffing the public health sector in Sierra Leone, 2005-11: findings from routine data analysis’

Report published by Rebuild Consortium

Data analysis reflection on HRH during FHCI: “This was a big [HW] increase on previous years’ trends, even allowing for the fact that some of these new recruits were already working but simply not on payroll”

Acronyms:

FCHI: Free Healthcare Initiative

CHC: Community Health Centre

CHO[s]: Community Health Officer[s]

CHP: Community Health Post

CHW[s]: Community Health Worker[s]

GoSL: Government of Sierra Leone

HRH: Human Resources for Health

HW[s]: Health Worker[s]

MCH Aides: Maternal and Child Health Aides

MCHP: Maternal and Child Health Post

MoHS: Ministry of Health and Sanitation

OOP: Out of Pocket [expenditure]

UHW[s]: Unsalaried Health Worker[s]