Staffing in public health facilities after the Ebola outbreak in rural Sierra Leone: How much has changed?

Introduction

The Ministry of Health and Sanitation of Sierra Leone has stipulated minimum staffing levels for all public health facility levels based on the Basic Package of Essential Health Services (BPEHS)¹. An observational study published in 2017 following the 2014–2015 Ebola outbreak reported alarming human resource deficits in public health facilities in Kailahun district of rural Sierra Leone². Of 805 recommended medical staff, the deficit was 501 (62%) and hovered over 50% at all levels of health facilities. Similarly, of 569 recommended non-medical staff, the deficit was 524 (92%). The overarching message was that to meet the BPEHS¹ standards, the Government would need to attract an additional 1,026 workers to Kailahun district over the period 2016–2020 (roughly 256 additional workers per annum).

The post-Ebola period presented an opportunity for the Government of Sierra Leone to devise a health services investment plan. This included a robust investment in human resources for health with a 2020 target for scale up of the BPEHS³. Both medical and non-medical staff are essential to maintain service delivery standards, including infection prevention and control practices, and both these staff cadres are included. The shortage in non-medical staff was found to have major implications for maintaining essential services related to infection prevention and control (IPC), such as screening and triage, health facility and personal hygiene as well as waste management².

Three years have now passed since the end of the Ebola outbreak and the operational question is “what has changed” in terms of progress towards achieving BPEHS standards.

Among all public health facilities in Kailahun district of Sierra Leone and in relation to BPEHS standards, we thus assessed staffing levels (medical and non-medical) one month before the onset of the Ebola outbreak, during the last month of the outbreak, and 16 months thereafter.

Methods

This was a comparative cross-sectional study using programme data. The study setting has been described before². The study site was Kailahun district, the first district affected by the Ebola outbreak in Sierra Leone. It shares borders with the Republic of Liberia and Guinea. The health infrastructure is tiered into tertiary hospitals, district hospitals and Peripheral Health Units. The current study included all 82 functional public health facilities.

Pre-service training of health care workers is carried out by the Ministry of Tertiary and Higher Education. Upon completion of training, health workers are recruited by the Public Service Commission of the Government of Sierra Leone. Financing of health workers once recruited into the civil service is largely carried out by the Government of Sierra Leone through a consolidated fund. The Human Resource Directorate of the Ministry of Health and Sanitation has the responsibility of posting staff to health facilities across the country. However, due to budgetary limitations on paying salaries, many health care workers serve as volunteers in health facilities and are not on a regular payroll. The International Monetary Fund macro-economic restrictions on fiscal space, in particular the wage bill, hampers the recruitment and hiring of health workers⁴, and this has been a major barrier in increasing staff numbers in relation to the BPEHS.

The study population included all health workers in these health facilities. We disaggregated staff deficits by medical and non-medical staff (for a full list see Table 5 & Table 6 of Squire et al. 2017)². We assessed staffing levels at 16 months post-Ebola (March 2017), and compared to previously reported staffing levels for pre-Ebola (April 2014) and the end of the outbreak (November 2015)¹.

April 2014 was immediately prior to the Ebola outbreak and thus representative of the human resource situation before the outbreak. November 2015 was the month when Sierra Leone was declared Ebola-free, and thus representative of the end-situation after Ebola. March 2017 was selected because the revised BPEHS was launched two years prior to this date, and some progress should have been expected.

Data variables were sourced from the monthly district staff list (District Health Information Systems; DHIS2) and the Human Resource Management Information System. Deficits in staffing levels were derived by subtracting the actual levels from the stipulated levels.

Ethics approval was obtained from the Sierra Leone Ethics and Scientific Review Board (dated 18 December 2018) and the Union Ethics Advisory Group (International Union against Tuberculosis and Lung Disease, Paris, France; UAG number 71/18). Since anonymized programme data were used, the requirement for informed consent was waived.

Results

Table 1 shows the medical staffing levels in relation to BPEHS standards. Of 805 recommended medical staff during the pre-Ebola and intra-Ebola periods, deficits were 539 (67%) and 528 (65%) respectively. During the post-Ebola period, a total of 815 medical staff were recommended, but the deficit was 490 (60%; a 5% improvement over the intra-Ebola period). When stratified by health facility levels, human resource gaps ranged between 31% and 71%.

Table 2 shows non-medical staffing levels in relation to BPEHS standards. The overall deficit remained the same at the three time-points. Of 569 recommended non-medical staff during pre- and post-Ebola, the deficits were 526 (92%) and 525 (92%), respectively. During the post-Ebola period, of 574 recommended non-medical staff, the deficit was 528 (92%).

By March 2017 and well into the post-Ebola period, a total of 1,389 health worker positions (medical and non-medical) were recommended by BPEHS, but only 371 (27%) were filled, resulting in an overall human resource deficit of 1,018 (73%).

Discussion

This is the first study assessing staffing levels (medical and non-medical) 16 months into the post-Ebola period and comparing the status with pre- and intra-Ebola periods. The situation remains alarming with a 60% deficit for medical and 92% deficit for non-medical staff. We need to reiterate our earlier urgent call for bold policies and donor support that goes beyond “business as usual.”⁵ In addition to enhancing staff training, further action could include rapid mobilization of financial resources for employment of non-medical and support staff, including those currently out of public service and reinstatement of retired medical personnel still fit enough to work². Importantly the macro-economic restrictions on the wage bill imposed by the International Monetary Fund (IMF) hamper recruitment and adequate salary levels⁴. These need to be boldly tackled. Whether or not the BPEHS standards are realistic and adaptation thereof may also need consideration.

The strengths of the study are that we included all district public health facilities, all human resource cadres and similar data prior to, during and after the outbreak. The main limitation is that we might have excluded some staff not on regular payrolls (those working on a volunteer basis), although we believe this is unlikely to offset or negate our study findings.

There are two key messages from this study. First, at the current rate of 5% improvement in the medical staff deficit over the 16-month post-Ebola period (65% intra-Ebola to 60% post-Ebola), it will take an additional 12 years to achieve BPEHS standards - too little, too slow!

Second, the persistent 92% gap for non-medical staff has major implications for future Ebola and infectious disease outbreaks⁶. Essential services for infection prevention and control at health facilities and the implementation of personal hygiene measures and effective waste management depend on non-medical staff. In the unfortunate event of a new Ebola outbreak, the current scenario would result in a déjà vu of high transmission among health workers and the community at large⁷. Ending the restrictive wage bill⁴ is vital to mobilize the needed financial resources and rapidly employ and deploy staff.

In conclusion, with an overall health worker deficit of 1,018, 16 months into the post-Ebola period compared to a deficit of 1,026 during the Ebola outbreak, “nothing has really changed.” We reiterate our call for strong political will, international collaboration, generous funding and a change in hiring restrictions imposed by the IMF.

Data availability