The free health care initiative: how has it affected health workers in Sierra Leone?

There is an acknowledged gap in the literature on the impact of fee exemption policies on health staff, and, conversely, the implications of staffing for fee exemption. This article draws from five research tools used to analyse changing health worker policies and incentives in post-war Sierra Leone to document the effects of the Free Health Care Initiative (FHCI) of 2010 on health workers.Data were collected through document review (57 documents fully reviewed, published and grey); key informant interviews (23 with government, donors, NGO staff and consultants); analysis of human resource data held by the MoHS; in-depth interviews with health workers (23 doctors, nurses, mid-wives and community health officers); and a health worker survey (312 participants, including all main cadres). The article traces the HR reforms which were triggered by the FHCI and evidence of their effects, which include substantial increases in number and pay (particularly for higher cadres), as well as a reported reduction in absenteeism and attrition, and an increase (at least for some areas, where data is available) in outputs per health worker. The findings highlight how a flagship policy, combined with high profile support and financial and technical resources, can galvanize systemic changes. In this regard, the story of Sierra Leone differs from many countries introducing fee exemptions, where fee exemption has been a stand-alone programme, unconnected to wider health system reforms. The challenge will be sustaining the momentum and the attention to delivering results as the FHCI ceases to be an initiative and becomes just 'business as normal'. The health system in Sierra Leone was fragile and conflict-affected prior to the FHCI and still faces significant challenges, both in human resources for health and more widely, as vividly evidenced by the current Ebola crisis.