Unsalaried health workforce research in Sierra Leone
The objective of this research is to establish what impact Sierra Leone’s reliance on unsalaried health workers has on healthcare delivery and health outcomes.
Since the 2010 introduction of Sierra Leone’s healthcare fee exemption for pregnant women and children under five years of age, the country’s somewhat improved public health system has been strained by the informal deployment of trained nurses and nursing aids – and more recently also midwives and community health officers – as ‘volunteer’ health workers within primary healthcare facilities and hospitals.
While their presence provides additional human resources, the fact that these extra pairs of hands are completely unsalaried means that the informal strategies that are used to reward these individuals leads to a range of unintended negative consequences.
The programme is funded by Research Ireland.
Watch a video of our research findings
Research approach and outcomes
The Sierra Leone research team was facilitated in their research by the Sierra Leone Ministry of Health and worked with a national researcher, Dr Dinsie Williams and local translators, while also convening regular meetings with national and international non-governmental organisations and aid donors working in the health sector in Sierra Leone.
The Sierra Leone unsalaried health worker study updated part of a much wider 2026 human resources for health (HRH) audit by collecting data on salaried and unsalaried health workers deployed in primary healthcare facilities (so-called PHUs) by the district health authorities. 10 out of 16 districts shared their HRH data, demonstrating that the total number of clinical health professionals deployed in primary care facilities across the majority of Sierra Loene’s PHU was unsalaried; just over 50% was deployed as a ‘volunteer’, an increase compared to 2016, when 36% of clinical staff were unsalaried volunteers (MoHS 2016).
For health workers, there is overwhelming evidence that both salaried and unsalaried health workers appear to adopt ‘coping strategies’, which include informal charging, selling medicine purchased privately.
For unsalaried workers, hardship is evident. Most interviewed health workers listed a range of additional jobs and ‘hustles’ they were engaged in; buying items locally/at market and selling it elsewhere at a mark-up: palm oil, rice, charcoal. The soliciting of payments from patients was described as ‘being given gifts, incentives, recognitions’.
Health service users entitled to free healthcare also highlighted problems accessing free care and medicine, stress and uncertainly caused by unknown cost for care, as well as coping with costs, alternative care providers.
Conclusions
Combined quantitative and qualitative data suggests that the widespread use of unsalaried health workers leads to their widespread use of coping strategies.
The unsalaried health workforce creates a conducive environment in health facilities, in which charging fee-exempted patients has become common-place, which creates a barrier to access to care and causes delays in care seeking when it is needed most.
The sale of medicines purchased by healthcare workers, salaried and unsalaried, has become an important source of income, and is accompanied with huge perverse incentives, including the sale of too many anti-microbial medications and wrong dosages, linked to what patients can afford.
Finally, this study has observed frequent absenteeism among salaried staff, which appears to be related to the clinical volunteer staff spending the majority of their time at health facilities (in rural areas especially), thus covering night and weekend shifts, even if these staff members may not be able to provide the expertise that some of more senior, absent staff, can provide.
The team
- Pieternella Pieterse
- Federico Saracini