Presentation given at the Global Symposium on Health Systems Research 2014

1. Path dependency and windows of
opportunities – lessons learned on policy-making
in post-conflict settings
The case of HRH policies in Sierra Leone, 2002-2012
3rd Global Symposium on Health System Research
Maria Paola Bertone, Mohamed Samai,
Joseph Edem-Hotah, Sophie Witter
ReBUILD is a 6 year £6million research project funded by the UK Department for International Development (DFID)
Funded by

2. What is ReBUILD?
6 partners;
four
countries
2011 -
2017
DFID funded
research
consortium
Understanding how to
strengthen health
financing and human
resource policy and
practice in countries
recovering from conflict

3. Initial hypotheses
Decisions made early
post-conflict can steer
the long term
development of the
health system (path
dependency)
The immediate post-conflict
period may
allow for the opening
of a political ‘window
of opportunity’ for
reform
Starting point for this study
Case study Research questions
Longitudinal study
to explore the HRH
policy making
trajectory in post-conflict
Sierra
Leone
2002-2012
1. How have HRH policies
evolved in the shift away
from conflict?
2. What have been the
reform objectives and
mechanisms?
3. What influenced the
trajectory? What are the
drivers of policy making?
What defines the timing
and the political space for
reform?
4. What lessons can be
learned?

4. Methods
 Study within the larger research project on HW incentives
 Qualitative data collection
 Documentary review (n=76)
 Half-day stakeholder meeting (23 participants)
 Interviews with key informants at central level (n=23)
 Chronological narration + policy analysis tools to identify key
issues
Limitations:
 Majority of participants, key informants and documents are from MoHS;
 Few documents refer to the HRH situation prior to 2009;
 Only a few respondents were present in Sierra Leone and engaged in HRH
policy-making during the immediate post conflict period.

5. Three phases of HRH policy-making
First phase: recovery & early development of
HRH policies
Second phase: launch of
FHCI and related HRH
policies
Third phase: post-FHCI policy-making
2006 2007 2008 2009 2010 2011 2012
2002-2009 2009-2010 2011-2012

6. Fire-fighting phase: 2002-2009
 Initially: many players (NGOs) and limited control by the MoHS
“After the war, it was complete chaos. The NGOs came and went […]. They employed the nurses
directly, without even consulting the Ministry. […] But this was a war. We had to bend backwards in the
Ministry” (SM – MoHS).
 Start of recovery: broad HRH policies developed but limited ability to
implement them; limited data. Official documents highlight challenges
and describe potential solutions, while they rarely propose actual
implementation plans
 Lack of clear strategic view, and fluid and uncertain policy context
The HRH Development Plan 2004–2008 states that “a certain flexibility will be allowed in the proposed
activities, given the current level of uncertainty regarding the exact nature of the reforms” (p.80 –
italics added).

7. Strengthening and
reforming phase: 2009 -
2010
FHCI triggered series of sectoral and HRH changes
 Improved coordination (HRH working group) and specific TA for the
design of necessary HRH reforms
 Several-fold increase of HWs salaries, skewed towards higher cadres (2010)
 Introduction of a Staff Sanction Framework to reduce absenteeism (2010-11)
 Payroll cleaning (2010) – 850 phantom HWs were removed (around 12% of the
total), while 1000 new HWs were added
 Fast-track recruitment in districts (2010)
 As the implementation of reforms became more coherent and
operational, budgeted plans and expenditure frameworks begun to
appear.
 Substantial donors’ funding to sustain these reforms (DfID and GF)

8. Post big-bang: 2011-
2012
 Reforms discussed during FHCI preparation are introduced :
 Implementation of a Performance-Based Incentive scheme in primary
healthcare units (2011)
 Introduction of a rural allowances for health workers in remote posts (2011)
 Performance contracts introduced for Ministers, Permanent Secretary and
Directors (2011-12)
 New HRH Policy and HRH Strategic Plan, including training policy
(2012)
 Official documents which give ex-post shape to the reforms and changes that
had already taken place at operational level
 Pace of change now slowing: less momentum and many
implementation challenges

9. Policy drivers and enablers
 Impossible to separate from FHCI drivers
“I believe, for the past 10 years, that free health care was a big turning point, because before
gradually everything was coming up. The free health care was big turning point to accelerate the
improvement”. (KII – donor).
 High-level political pressure and leadership. Urgency and political
pressure for successful FHCI were key to push MoHS and partners
to approve and design HRH reforms.
 Development partners - funding from DfID and GF, but also
consensus to back the initiative by all major players (despite some
discussion between donors)
 Donor support allowed for high level of ad hoc TA which enabled changes to
be operationalised.
 Sense of need for change

10. Issues and remaining challenges
 Urgency in the design and not enough time to discuss all possible
options
 Preference for one-off strategies and short term policies
 Focus on the design, and less attention to implementation
 Sustainability of the reform in the long run, when technical and
financial support will diminish
 Consequences of a series of reform based on short-lived political
pressure
Health system remains fragile, as evidenced in Ebola outbreak

11. What about the ‘post-conflict’ context?
“Sierra Leone has moved beyond that [post-conflict phase] now. There is not much link. We can’t
use that as an excuse”.(KII– MoHS).
“I don’t think we are post-conflict anymore. [...] According to my feeling, I wouldn’t call the country
‘post-conflict’, [...] and also I don’t like it because it brings us back in the past”. (KII– NGO).
 Some possible post-conflict features:
 Need for broader reforms in order to implement FHCI, given the weak state of
the health system
 Fluidity of power relations
 Sense of need for change?
 Path dependency?
 Choice not to contract-out services, high levels of State engagement
 Window of opportunity for reform in the immediate post-conflict?
 Timing of reforms much later (8 yrs)
 Drivers related to the political (2nd govt. after war) and international climate

12. Hypotheses revisited & lessons learned
 Path dependency is important to understand health system
reforms, but sudden shifts are also possible given the right
conditions
 Window of opportunities for reform may not be necessarily related
to post-conflict
 Political uncertainty and (politically) fragmented health systems are unlikely to
produce ‘big non-incremental change’ (Wilsford 1994, Pavignani 2011)
 Political leadership and stability + external support can create such
opportunities for reform
 But how to sustain momentum for reform (incl. implementation) over time?
 Methodologically: longitudinal studies can be illuminating on post-conflict
dynamics, but data are scarce and difficult to retrieve,
especially on the immediate post-conflict period

13. Bertone, M., Samai, M., Edem-
Hotah, J. and Witter, S.
(2014) A window of
opportunity for reform in
post-conflict settings? The
case of Human Resources
for Health policies in Sierra
Leone, 2002-2012. Conflict
and Health, 8:11.
http://www.conflictandhea
lth.com/content/pdf/1752-
1505-8-11.pdf
Ph: Maria Paola Bertone