The Institute for Global Health and Development

Permanent URI for this collectionhttps://eresearch.qmu.ac.uk/handle/20.500.12289/9

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Sources, determinants and utilization of health workers’ revenues: Evidence from Sierra Leone
(Oxford University Press, 2016-04-06) Bertone, Maria Paola; Lagarde, Mylene
Exploring the entire set of formal and informal payments available to health workers (HWs) is critical to understand the financial incentives they face and devise effective incentive packages to motivate them. We investigate this issue in the context of Sierra Leone by collecting quantitative data through a survey and daily logbooks on the incomes of 266 HWs in three districts, and carrying out 39 qualitative in-depth interviews. We find that, while earnings related to the HWs official jobs represent the largest share, their income is fragmented and composed of a variety of payments, and there is a large heterogeneity in the importance of each income source within the total remuneration. Importantly, each income has different features in terms of regularity, reliability, ease of access, etc. Our analysis also reveals the determinants of the incomes received and their level based on individual and facility characteristics, and finds that these are not in line with HRH policies defined at national level. Additionally, from their narratives, it emerges that HWs are ‘managing’, in the sense both of ‘getting by’ and of enacting financial coping strategies, such as mental accounting (spending different incomes differently), income hiding to shelter it from family pressures, and re-investment of incomes to stabilize overall earnings over time, in order to ensure their livelihoods and those of their families. These strategies question the assumption of fungibility of incomes and the neutrality of increasing or regulating one rather than another of them. Together, our findings on earning and income use patterns have important policy implications for how we go about (re)thinking financial incentive strategies.
The myth of the 1-day training: The effectiveness of psychosocial support capacity-building during the Ebola outbreak in West Africa
(Cambridge University Press, 2019-05-07) Horn, Rebecca; O'May, Fiona; Esliker, Rebecca; Gwaikolo, Wilfred; Woensdregt, Lise; Ruttenberg, Leontien; Ager, Alastair
Background - In emergencies and resource-poor settings, non-specialists are increasingly being trained to provide psychosocial support to people in distress, with Psychological First Aid (PFA) one of the most widely-used approaches. This paper considers the effectiveness of short training programmes to equip volunteers to provide psychosocial support in emergencies, focusing particularly on whether the PFA training provided during the Ebola outbreak enabled non-specialists to incorporate the key principles into their practice. Methods - Semi-structured interviews were conducted in Sierra Leone and Liberia with 24 PFA trainers; 36 individuals who participated in PFA training; and 12 key informants involved in planning and implementing the PFA roll-out. Results - Findings indicate that many PFA ToTs were short and rarely included content designed to develop training skills. As a result, the PFA training delivered was of variable quality. PFA providers had a good understanding of active listening, but responses to a person in distress were less consistent with the guidance in the PFA training or with the principles of effective interventions outlined by Hobfoll et al. Conclusions - There are advantages to training non-specialists to provide psychosocial support during emergencies, and PFA has all the elements of an effective approach. However, the very short training programmes which have been used to train non-specialists in PFA might be appropriate for participants who already bring a set of relevant skills to the training, but for others it is insufficient. Government/NGO standardisation of PFA training and integration in national emergency response structures and systems could strengthen in-country capacity.
The bumpy trajectory of performance-based financing for healthcare in Sierra Leone: agency, structure and frames shaping the policy process
(BioMed Central, 2018-10-20) Bertone, Maria Paola; Wurie, Haja; Samai, Mohamed; Witter, Sophie
Background - As performance-based financing (PBF) has been increasingly implemented in low-income countries, a growing literature has developed, assessing its effectiveness and, more recently, focussing on the political dynamics of PBF introduction and implementation. This study contributes to the latter body of literature by exploring decision-making processes on PBF in Sierra Leone during the 2010–2017 period. Sierra Leone presents an interesting case because of the ‘start-stop-start’ trajectory of PBF. Methods - The qualitative case study is based on a document review and 25 key informant interviews with national stakeholders and international actors. Documents and interviews were analysed based on a political economy framework focusing on actors and structure, but also making use of concepts drawn from interpretive policy analysis to look at frames. Results - Our analysis describes the process of negotiation and re-negotiation of PBF in Sierra Leone, highlighting the role of different players, both internal and external, their ideas, capacity and power relations, and the shifting narratives around PBF. It is shown that external actors driving the debate make use of ‘frames’, both actual (i.e., defining the timing and pace of the discussions, the funding available, etc.) and metaphorical (i.e., how PBF is interpreted, defined and understood) to fit in and influence the debate. This is facilitated by the lack of capacity and resources in the fragile setting. Other strategies, such as ‘venue shopping’ are employed, though they may add to fragmentation in the volatile context. Conclusions - The retrospective view of the study has an analytical advantage, but findings are also relevant to guide practice. Although power relations and rent-seeking issues are difficult to overcome in resource and capacity-constrained settings, more attention could be paid to other elements. In particular, adopting shared frames to ensure a common and inclusive understanding of technical concepts such as PBF may be useful to ensure the political sustainability of reforms. Also, the ‘actual frames’ which define negotiation and implementation should remain flexible, allowing for disrupting events (e.g., the Ebola epidemic in Sierra Leone) as well as for time to develop national capacity and ownership in order to ensure longer-term political support and better health system integration.
An exploration of the political economy dynamics shaping health worker incentives in three districts in Sierra Leone
(Elsevier, 2015) Bertone, Maria Paola; Witter, Sophie
The need for evidence-based practice calls for research focussing not only on the effectiveness of interventions and their translation into policies, but also on implementation processes and the factors influencing them, in particular for complex health system policies. In this paper, we use the lens of one of the health system's 'building blocks', human resources for health (HRH), to examine the implementation of official policies on HRH incentives and the emergence of informal practices in three districts of Sierra Leone. Our mixed-methods research draws mostly from 18 key informant interviews at district level. Data are organised using a political economy framework which focuses on the dynamic interactions between structure (context, historical legacies, institutions) and agency (actors, agendas, power relations) to show how these elements affect the HRH incentive practices in each district. It appears that the official policies are re-shaped both by implementation challenges and by informal practices emerging at local level as the result of the district-level dynamics and negotiations between District Health Management Teams (DHMTs) and nongovernmental organisations (NGOs). Emerging informal practices take the form of selective supervision, salary supplementations and per diems paid to health workers, and aim to ensure a better fit between the actors' agendas and the incentive package. Importantly, the negotiations which shape such practices are characterised by a substantial asymmetry of power between DHMTs and NGOs. In conclusion, our findings reveal the influence of NGOs on the HRH incentive package and highlight the need to empower DHMTs to limit the discrepancy between policies defined at central level and practices in the districts, and to reduce inequalities in health worker remuneration across districts. For Sierra Leone, these findings are now more relevant than ever as new players enter the stage at district level, as part of the Ebola response and post-Ebola reconstruction.
Ebola in the context of conflict affected states and health systems: Case studies of Northern Uganda and Sierra Leone
(BioMed Central, 2015-08) McPake, Barbara; Witter, Sophie; Ssali, S.; Wurie, H.; Namakula, Justine; Ssengooba, F.
Ebola seems to be a particular risk in conflict affected contexts. All three of the countries most affected by the 2014-15 outbreak have a complex conflict-affected recent history. Other major outbreaks in the recent past, in Northern Uganda and in the Democratic Republic of Congo are similarly afflicted although outbreaks have also occurred in stable settings. Although the 2014-15 outbreak in West Africa has received more attention than almost any other public health issue in recent months, very little of that attention has focused on the complex interaction between conflict and its aftermath and its implications for health systems, the emergence of the disease and the success or failure in controlling it. The health systems of conflict-affected states are characterized by a series of weaknesses, some common to other low and even middle income countries, others specifically conflict-related. Added to this is the burden placed on health systems by the aggravated health problems associated with conflict. Other features of post conflict health systems are a consequence of the global institutional response. Comparing the experience of Northern Uganda and Sierra Leone in the emergence and management of Ebola outbreaks in 2000-1 and in 2014-15 respectively highlights how the various elements of these conflict affected societies came together with international agencies responses to permit the outbreak of the disease and then to successfully contain it (in Northern Uganda) or to fail to do so before a catastrophic cost had been incurred (in Sierra Leone). These case studies have implications for the types of investments in health systems that are needed to enable effective response to Ebola and other zoonotic diseases where they arise in conflict- affected settings.
'I don't need an eye for an eye': Women's responses to intimate partner violence in Sierra Leone and Liberia
(Taylor & Francis, 2016-02) Horn, Rebecca; Puffer, Eve S.; Roesch, Elisabeth; Lehmann, Heidi
This paper explores the possibilities for agency in intimate partner violence (IPV) situations from the perspective of women in Sierra Leone and Liberia using focus group discussions (N groups = 14, N participants = 110) and individual interviews (N = 20). Findings identify multiple interrelated factors influencing the decisionmaking of women experiencing IPV. At the individual level, emotional factors and women's knowledge of their rights and options influence their decision-making. At the relational level, the role of neighbours, family and friends is crucial, both for emotional support and practical assistance. At the community level, more formal structures play a role, such as chiefs and women's groups, though their effectiveness varies. At the structural level are barriers to effective responses, including a poorly functioning criminal justice system and a social system in which children often stay with fathers following separation or divorce. Strong cultural beliefs operate to keep women in abusive relationships. We identify implications for prevention and response services and make practice recommendations. Since the desire of most women experiencing IPV was to live in peace with their husbands, interventions should respect women's priorities by focusing more on prevention and interventions to end the violence, rather than solely assisting women to leave violent relationships.
Health workers' experiences of coping with the Ebola epidemic in Sierra Leone's health system: A qualitative study
(BioMed Central, 2018-04-05) Raven, Joanna; Wurie, Haja; Witter, Sophie
The 2014 Ebola Virus Disease epidemic evolved in alarming ways in Sierra Leone spreading to all districts. The country struggled to control it against a backdrop of a health system that was already over-burdened. Health workers play an important role during epidemics but there is limited research on how they cope during health epidemics in fragile states. This paper explores the challenges faced by health workers and their coping strategies during the Ebola outbreak in four districts - Bonthe, Kenema, Koinadugu and Western Area - of Sierra Leone.
The victim-witness experience in the Special Court for Sierra Leone.
(A B Academic Publishers, 2009) Horn, Rebecca; Charters, Simon; Vahidy, Saleem
This paper reports the findings of an interview study of 144 victim-witnesses who testified in the Special Court for Sierra Leone (SCSL). Witnesses expressed satisfaction with the preparation they received for testifying from their lawyers, particularly appreciating emotional support, as well as practical preparations. Victim-witnesses generally evaluated their interactions with all court staff positively, and reported feeling well-treated by the Court. The experience of cross-examination was difficult for a large proportion of witnesses in the current study, but an even larger group of witnesses reported the experience to be positive. For some witnesses, the experience of successfully coping with the challenge of cross-examination may be empowering. The feelings reportedly experienced by witnesses during their testimony are similarly mixed: a large proportion reported painful feelings, but others reported feeling confident, relieved and happy when they testified. The importance of continued post-testimony contact with witnesses is supported by the current study; witnesses expressed a strong desire for ongoing contact with the SCSL. According to witnesses' own evaluations, their security was not negatively affected by their involvement with the court. This indicates that the SCSL has been largely successful in its attempt to protect the identities of those who testify in its trials.

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