[version 1; peer review: 3 approved with reservations]
No competing interests were disclosed.
In one of the worst Ebola affected districts in Sierra Leone, we assessed staffing levels measured against these stipulated standards before, during, and 16 months after the Ebola outbreak.
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 reflects the end-situation after Ebola. March 2017 was two years since the launch of the BPEHS, and some progress should be expected.
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)
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 Leone
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.
This was a comparative cross-sectional study using programme data. The study setting has been described before
The study population included all health workers in these health facilities. 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)
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 substracting 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.
| Pre-Ebola
|
Intra-Ebola
|
Post-Ebola
|
||
|---|---|---|---|---|
|
|
Recommended | 805 | 805 | 815
|
| Actual | 266 | 277 | 325 | |
| Human resource gap | 539 (67) | 528 (66) | 490 (60) | |
|
|
||||
| District Hospital | Recommended | 256 | 256 | 256 |
| Actual | 66 | 77 | 74 | |
| Human resource gap | 190 (74) | 179 (70) | 182 (71) | |
| CHC | Recommended | 252 | 252 | 252 |
| Actual | 71 | 77 | 97 | |
| Human resource gap | 181 (72) | 175 (69) | 155 (62) | |
| CHP | Recommended | 240 | 240 | 265
|
| Actual | 104 | 101 | 125 | |
| Human resource gap | 136 (57) | 139 (58) | 140 (53) | |
| MCHP | Recommended | 57 | 57 | 42
|
| Actual | 25 | 22 | 29 | |
| Human resource gap | 32 (56) | 35 (61) | 13 (31) |
BPEHS: Basic Package of Essential Health Services document for improving health service delivery in Sierra Leone; CHC: Community Health Center; CHP: Community Health Post; MCHP: Maternal and Child Health Post
1 Includes staff such as specialist doctors, general practitioners, clinical officers, nurses and midwives
2 Pre-Ebola – April 2014; Intra-Ebola – November 2015; Post-Ebola – March 2017
3 The overall recommended numbers of staff as per the BPEHS increased from 805 during the pre- and intra-Ebola period to 820 in the post-Ebola period as one new facility was added in the post-Ebola period.
4 Similarly, during the post-Ebola period, 5 MCHPs were upgraded to CHPs increasing the staffing requirement for the CHPs from 240 to 265.
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%).
| Pre-Ebola
|
Intra-Ebola
|
Post-Ebola
|
||
|---|---|---|---|---|
|
|
Recommended | 569 | 569 | 574
|
| Actual | 43 | 44 | 46 | |
| Human resource gap | 526 (92) | 525 (92) | 528 (92) | |
|
|
||||
| District Hospital | Recommended | 88 | 88 | 88 |
| Actual | 31 | 31 | 34 | |
| Human resource gap | 57 (65) | 57 (65) | 54 (61) | |
| CHC | Recommended | 98 | 98 | 98 |
| Actual | 9 | 9 | 8 | |
| Human resource gap | 89 (91) | 89 (91) | 90 (92) | |
| CHP | Recommended | 288 | 288 | 318
|
| Actual | 3 | 4 | 4 | |
| Human resource gap | 285 (99) | 284 (99) | 314 (99) | |
| MCHP | Recommended | 95 | 95 | 70
|
| Actual | 0 | 0 | 0 | |
| Human resource gap | 95 (100) | 95 (100) | 70 (100) |
BPEHS: Basic Package of Essential Health Services document for improving health service delivery in Sierra Leone; CHC: Community Health Center; CHP: Community Health Post; MCHP: Maternal and Child Health Post
1 Includes staff such as administrative staff, cleaners, cooks, maintenance workers, drivers and security personnel
2 Pre-Ebola – April 2014; Intra-Ebola – November 2015; Post-Ebola – March 2017
3 The overall recommended numbers of staff as per the BPEHS increased from 569 during the pre- and intra-Ebola period to 574 in the post-Ebola period as one new facility was added in the post-Ebola period.
4 Similarly, during the post-Ebola period, 5 MCHPs were upgraded to CHPs increasing the staffing requirement for the CHPs from 288 to 318.
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.”
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 outbreaks
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.
Open Science Framework: Squire J. Squire_James_SORTIT2_HRH_data 2019.
Data are available under the terms of the
The Sierra Leone Health Management Information Systems, the District Health Information System 2 (DHIS2), is accessible with a Ministry of Health and Sanitation login through
This research was conducted through the Structured Operational Research and Training Initiative (SORT IT), a global partnership coordinated by the Special Programme for Research and Training in Tropical Diseases at the World Health Organization (WHO/TDR) and implemented with partners. The training model is based on a course developed jointly by the International Union Against Tuberculosis and Lung Disease (The Union) and Medécins sans Frontières (MSF). The specific SORT IT programme which resulted in this publication was jointly developed and implemented by: WHO/TDR, the Sierra Leone Ministry of Health and Sanitation, WHO Sierra Leone and the Centre for Operational Research, The Union, Paris, France. Mentorship and the coordination/facilitation of the SORT IT workshops were provided through the Centre for Operational Research, The Union, Paris, France; Alliance for Public Health, Ukraine; Institute of Tropical Medicine, Antwerp, Belgium; and Sustainable Health Systems, Freetown, Sierra Leone.
This study gives a simple, but clear, description of the gap between Sierra Leone's health structure staffing ambitions and the actual state of affairs in Kailahun over the last several years. By merely measuring the difference between what the ministry of health and sanitation has set as staffing objectives and what it has achieved, the study is no more complicated than it needs to be. As such, the methods and results sections are suitably short and to the point.
That being said, the paper would profit from going into greater depth in the discussion. This is hardly the first study to examine staffing shortfalls in Sierra Leone. The authors cite their own previous work, but there are other papers that merit mention in this domain. A quick PubMed search of "Sierra Leone Staffing" brings up a number of studies, some of which the authors may wish to include in their discussion of health structure staffing in Sierra Leone.
The reader is also left in the dark as to how the Basic Package of Essential Health Services was put together and whether the levels set in this standard were tailored to well assessed needs in Sierra Leone, imported from another context, or are aspirational. As such, it is difficult for the reader to guess at the impact of the measured gap.
The paper would benefit from some additional exploration of not meeting this standard. The authors speculate about the consequences of the severe non-medical under-staffing in terms of being unable to cope with infectious disease outbreaks because of insufficient hygiene staff, but at a 92% deficit of "administrative staff, cleaners, cooks, maintenance workers, drivers, and security personnel" (and this list should perhaps appear somewhere in the body of the paper and not just in a footnote to table 2), the day to day consequences should go well beyond this.
The reader might also profit from some information about why the gap has persisted. The recommendation to mobilize additional financial resources suggests that the underlying problem is insufficient funding, which seems reasonable, but the foundation for this recommendation is never laid by any mention of what has caused the gap to remain. Perhaps the money is available but the qualified people are in the middle of their training programs? Other problems could be at work as well, but the authors do not explore this next logical step following from their findings.
This is a nice simple study, but the readers would profit from the authors shedding more light on the meaning of their findings.
Is the work clearly and accurately presented and does it cite the current literature?
Partly
If applicable, is the statistical analysis and its interpretation appropriate?
Not applicable
Are all the source data underlying the results available to ensure full reproducibility?
Yes
Is the study design appropriate and is the work technically sound?
Yes
Are the conclusions drawn adequately supported by the results?
Partly
Are sufficient details of methods and analysis provided to allow replication by others?
Yes
Reviewer Expertise:
Epidemiology, filovirus outbreak management, public health
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
Response: Thanks for the comment. We do agree that other studies have looked at staffing issues in Sierra Leone. However, this is the first study that has assessed the implementation of the BPEHS in relation to the Ebola outbreak and the references we have included in the paper relate to this theme. We thank you for your understanding. Response: The BPEHS is the national standard that stipulates the minimum staffing for each type of public health facility level, which is critical to maintain service delivery standards. The BPEHS has been described before and we have included its details and justification for its use in the introduction. The standards are not aspirational but a necessary requirement. Response. Thank you for this important comment. In the related article that was already published and duly referenced entitled “The Ebola outbreak and staffing in public health facilities in rural Sierra Leone: who is left to do the job?”, we disaggregated the staffing deficit by cadre. We cited this article in the current study. Since there were no significant changes in the staffing levels, we decided not to duplicate the same result in the current study. We have included a reference to the full list of medical and non-medical staff. Response: In the discussion we have mentioned the possible reasons (which are multiple) and actions that needs to be taken to address some of the root causes and why corrective action has not been forthcoming. In future research, we hope to consider determining the root causes Response: In the related article that was already published and duly referenced entitled “The Ebola outbreak and staffing in public health facilities in rural Sierra Leone: who is left to do the job?” we already touched the issues around IMF restrictions and retention issues and tried to avoid duplication in this current paper. We thank you for your kind consideration.
The article is very well written with clearly defined aim/research question and methodology designed to answer it.
The question of interest is of high importance as it relates to Ebola (highly contagious and dangerous virus) which could become a threat for the whole world. The problem discussed in the article (under-staffing) is worrisome and calls for an urgent actions.
It seems there is a need for more information on settings. Particularly regarding financing and hiring/staffing of the health facilities in the article.
While the presentation of the problem is clear it will be really interesting and important to understand root-causes of the problems which may help to solve the issues discussed. Most importantly if there was a standard setting for minimum staff levels by the Ministry (so, assuming there is political will) then what are the constrains for not increasing number of human resources. The lack of qualified professionals may cause the under-staffing of medical resources but we observe no change in the number of non-medical staff so there should be other causes preventing the capacity increase in terms of human resources. If the data is not available researchers might want to address it in the limitations and call for further investigation of the topic.
Is the work clearly and accurately presented and does it cite the current literature?
Yes
If applicable, is the statistical analysis and its interpretation appropriate?
Not applicable
Are all the source data underlying the results available to ensure full reproducibility?
Yes
Is the study design appropriate and is the work technically sound?
Yes
Are the conclusions drawn adequately supported by the results?
Yes
Are sufficient details of methods and analysis provided to allow replication by others?
Yes
Reviewer Expertise:
Operational research, Tuberculosis, HIV
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
Response: Thank you for this important comment. As suggested, we have included more information on the settings specifically addressing your concerns.
Response: The current study’s aim and objectives were to identify what is the deficit (the gap) in the health workforce in relation to Basic stipulated standards and not to address root-causes of the deficit. In the discussion we mentioned the possible reasons and actions that needs to be taken to address some of the root causes. In future research, we hope to consider determining the root causes.
Response: The BPEHS is the national standard that stipulates the minimum staffing for each type of public health facility, which is critical to maintain service delivery standards. The BPEHS target is to be achieved by 2020. However, with the current pace of implementation, this target will not be achieved by 2020. The constraints in increasing the health workforce are multiple and include limited available funds, availability of trained manpower, IMF restrictions etc. We have already highlighted the constraints and the urgent measures that need to be implemented to address the underlying staffing deficits.
Response: We have already discussed the underlying factors contributing to the observed deficits in both medical and non-medical staffing levels. We agree with the reviewer that more research is needed and have suggested areas that merit further research and investigation (in the Discussion).
I have found the study very interesting and partially relevant in flagging the deficit for minimal staffing by label of care (based on the BPEHS standards) in Sierra Leone.
Some of my question and concerns are:
Health Workforce (HWF) staffing usually measured based on population and there are intentional standards for developing countries. Why the authors are not interested to use or at least mention that? What is the catchment population of those health facilities and what is the health workforce staffing deficit based on the WHO criteria (for a developing country)? Do you need the HWF just to fulfil the BPEHS standard or is there any evidence suggesting compromisation of the routine health care service because of the stated HWF deficit. For prioritization and focused action, I would recommend the showing the dis-aggregated deficit from nurses, midwifes and doctors which would be much more important for the policy maker for action.
Is the work clearly and accurately presented and does it cite the current literature?
Partly
If applicable, is the statistical analysis and its interpretation appropriate?
Yes
Are all the source data underlying the results available to ensure full reproducibility?
Yes
Is the study design appropriate and is the work technically sound?
Partly
Are the conclusions drawn adequately supported by the results?
No
Are sufficient details of methods and analysis provided to allow replication by others?
Yes
Reviewer Expertise:
Human resource for health and Skin NTD
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
Dear Dr Wendemagegn Enbiale, Thank you for your review and insightful comments on the manuscript. We have responded to each of your points below. 1. Reviewer comment 1. Health Workforce (HWF) staffing usually measured based on population and there are international standards for developing countries. Why the authors are not interested to use or at least mention that? Response: Thank you for this comment. The Basic Package for Essential Health Services (BPEHS) is the national standard used to guide health workforce requirements in Sierra Leone. Despite the existence of global methods usually using a population-based measure the BPEHS has been adapted to the Sierra Leone content and thus more appropriate to measure health workforce gaps. In particular, the BPEHS allows us to quantify the real gap between the Government’s commitment and the actual status in terms of staffing. In addition, the international standard for staffing measures focus only on clinical staff. However, in the Ebola and post-Ebola context, non-clinical staffing are equally essential, especially in terms of infection prevention and control measures. Therefore, the use of the BPEHS is more appropriate as it allows assessment of both medical and non-medical staff cadres. In the introduction, we have added more explanation and references to clarify our stand to use the BPEHS as the yardstick in the introduction. We have also added more information of the BPEHS standard in the methods section. 2. Reviewer Comment 2: What is the catchment population of those health facilities and what is the health workforce staffing deficit based on the WHO criteria (for a developing country)? Response: This study is focused on a specific district, Kailahun and all health facilities in the district was included. Details of the Study setting and population was already reported in the previous paper for which this study is a follow up. We have referenced this paper and its contents in case the reader might wish for more information. As justified in point 1 above, since we utilised the BPEHS national standards, we do not see applying the WHO criteria as relevant to this study. 3. Reviewer comment 3: Do you need the HWF just to fulfil the BPEHS standard or is there any evidence suggesting compromiation of the routine health care service because of the stated HWF deficit. Response: Ensuring basic standards of Human resources for health, is one of the WHO health systems building blocks. It is essential to achieve this requirement if health facilities are to have the “hands on deck” to ensure proper and effective functioning of health systems to support the delivery of care to the population. The 2014-2016 Ebola outbreak with the resulting decline in the health workforce resulted in the collapse of even the most basic of routine health services. The BPEHS is the national standard that stipulate the minimum staffing for each type of public health facility, which is critical to maintain service delivery standards and our study shows that we are far from these standards. This gap will need to be filled. We have now added references to support the evidence on the health workforce deficit and its detrimental effect on health service delivery. 4. Reviewer comment 4: For prioritization and focused action, I would recommend the showing the dis-aggregated deficit from nurses, midwifes and doctors which would be much more important for the policy maker for action. Response: Thank you for this important comment. In the already published article “The Ebola outbreak and staffing in public health facilities in rural Sierra Leone: who is left to do the job?” which has been referenced in the current study, we disaggregated the staffing deficit by cadre. Since there were no significant changes in the staffing levels, we decided not to duplicate the same results in the current study. We thank you for your kind understanding.