Presentation made by Dr Sophie Witter at World Bank Fragility Forum, March 2016

1. Can donors really build
institutions?
Reflections on recent health sector experiences in Sierra Leone
Dr Sophie Witter
World Bank Fragility Forum 2016
Research for stronger health systems post conflict

2. Background on ReBUILD
Post conflict is a
neglected area
of health
system research
Opportunity
to set health
systems in a
pro-poor
direction
Focus on HRH
and health
financing but
also on health
system/state
building links
Choice of
focal
countries
enable distance
and close up
view of post
conflict
Decisions made early post-conflict can steer the long term
development of the health system

3. Background to talk
• Focus of research in Sierra Leone
• Talk based on indirect insights and observations on:
• What were the patterns of interaction between donors and MoHS during the
period, across different phases?
• Where institutions strengthened?
• If not, why not?
• Lessons, including how to improve the interaction

4. Underlying assumptions
• MoHS has core mandate to plan for, manage and regulate the health
sector – not the only, but a key institution
• Building of MoHS judged by:
• Its legitimacy – recognised as playing this core role on behalf of all citizens;
not contested or in competition with other organisations
• Its effectiveness – delivering good stewardship and services, which is
underpinned by:
• capacity – staffing, resources, flexibility, decision-space to carry out role
• Its resilience – ability to survive and function during and after shocks

5. 2009 2010 201220112006 2007 2008 2013 2014 2015 2016
First phase: early development of HRH policies
Second phase: launch of FHCI
and related HRH policies
Third phase: post-FHCI policy-
making
EVD and post-EVD policy-making
The four phases of HRH policy-making, Sierra Leone,
2002-16

6. First phase: 2002-2009
• ‘Fire-fighting’ phase: many players (NGOs) and limited control by the MoHS; broad HRH
policies developed but limited ability to implement them; limited data
“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).
• Official documents highlight challenges and describe potential solutions, while they rarely
propose actual implementation plans
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. Second phase: 2009 - 2010
• Strengthening and reforming phase: 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 (2010)
• Introduction of a Staff Sanction Framework to reduce absenteeism (2010-11)
• Payroll cleaning (2010) – 850 ghost HWs were removed (~12% of total), 1,000 new HWs added
• Fast-track recruitment at district level (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. Third phase: 2011-2012
Post-FHCI phase
• Reforms discussed during FHCI preparation are introduced :
• Implementation of a Performance-Based Financing scheme in PHUs (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 (2012)
• Official documents which give ex-post shape to the reforms and changes that had already taken place at
operational level
• Pace of change slowing after 2012: less momentum and many implementation challenges
Many commitments not kept, e.g. development of BEmOCs, improved procurement capacity
for drugs

9. Fourth phase (2013-15):pre/during/post EVD
2013: MoHS leadership hit by GAVI funding scandal
2014: Ebola – MoHS slow to respond
2015: Post-Ebola planning starts but MoHS is not at the centre
• Money and TA arrive
• Cycle repeats of
• Revival of HRH TWG
• Renewed cleaning of payroll
• Plans for mobile recruitment
• Review of all key HRH policy documents

10. GAVI scandal: tale of
unintended (negative)
consequences
• Story broke June 2013 – GAVI funds suspended; $1 million not
properly accounted for over 2008-11. Money gone to unsecured bank
accounts.
• Consequences: 15 or so top people (directors) suspended. None have
returned.
• Consequences for Ebola period: 9 months later, no-body in place in
key roles

11. Ebola: further weakening of mandate and
capacity
• Presidential task force and NERC/DERC took over – command and
control response
• Staffed with higher-paid diaspora staff
• Still partially in place – complaints also at district level
“MOHS was regarded as part of the problem during Ebola” (national KI,
Freetown, January 2016)

12. Post-Ebola: window of opportunity, but for
whom?
• Influx of money – $220.5m pledged to Sierra Leone (UNOCHA 2014)
• Rival power centres
• Presidential task force
• Presidential delivery unit
• HSS Hub
• Planning process undertaken by HSS Hub
• Paid by Bank at much higher rates
• Leading on ‘flagship programmes’, SLAs etc
• Reporting to MOHS in theory
• Still weak core institutions
• Tiny health financing team, few planners in the MoHS etc.

13. Patterns
• Periods of support, but focus is short term
• Capacity building in MoHS is not effective
Internal factors:
Chronic under-funding
Failure to reform
Poor terms and conditions
Systemic weaknesses, e.g. in financial
management
Failure to develop strong institutional vision
and leadership
External factors:
Funding unpredictable and short-term
Poor coordination between donors
Short-term objectives
Over-reliance on external TA
By-passing of MoHS
Brain drain of staff
Per diems
Capacity building focused on individuals,
not institutions “Government comes up with strategies but has no money to
implement” MoHS KI, January 2016

14. Implementation of HRH reforms
“They [MoHS at central level] don’t even communicate with us. We are dealing with the staff here, we know the staff
movement. [...] But they say that they have the data there. But sometimes they pay staff that are not even in remote areas”
(KII – DHMT)
“I mean, [PBF] is good in theory, but when it comes nine months later, I think it defeats the
whole purpose” (KII – DHTM).
“I heard many, many health workers, PHU staff, and DMOs talk about performance-based financing. I've never heard anyone
mention this remote area allowance”(KII – NGO).
“The real key issue is that with all of these policies and all of these strategies, none of them have been properly operationalised and none of them
have stayed around. Like, in 2002, there was a free health care policy announced [...] and then it just didn’t happen. So free health care is
announced again in 2010, and it’s like, OK, it’s happening, but is that going to slowly start to fall apart? If PBF is announced, it’s like, oh it comes and
then it stops, you know.” (KII – NGO).
Remote allowance: 5%-8% of income of all HWs (Dec. 2012)  delayed and then stopped from Jan. 2013
Performance Based Financing: 11% of income of HWs (Sept. 2013)  payments received more than one year later than services are performed
Conclusion and lessons

15. Conclusion
Donors are poor at
strengthening institutions,
especially when they are
fragile, weak in capacity and
hostage to fragmented support
and differing agendas
i.e. in settings where they most
need strengthening!

16. Lessons for donors
• Longer term partnerships
• Stability and continuity
• Generating better knowledge of institutional history and context
• Able to support institution within local political economy networks
• Supporting underlying systems that are contextually sustainable
• FM
• HMIS, HRIS, M&E
• Management
• Procurement
• Focus on institutional capacity building, including
• Strengthened horizontal (e.g. to MoF & Cabinet) and vertical relationships (with
districts)
• Developing more depth in core teams
• Ability to deliver and build on short term achievements (virtuous cycle)
• Gradually becoming a learning organisation
• Better internal communication – develop institutional culture

17. Increased transparency and accountability of
partners to MoHS
Only 5% of JPWF (2010-14) fully implemented, according to CMO (Jan 2015)
• Bulk of funds are vertical and by-pass MoHS
• NGOs report to donors, not MoHS
• Consultation with MoHS on core policy issues is not done in coherent and transparent way (current
example of PBF)
Donors must find ways to devolve resources and engage MoHS in oversight and policy-setting
• E.g. under clear and accountable SWAP types agreements, with transparent audit trails in place
demonstrating good governance and clear devolution of authority
• NGO programmes must be tied into agreement contracts, to deliver agreed outputs at district/national
level with DHMTs/MOHS and these should be monitored by a mutually agreed governance mechanism
• Support must be focused longer term on sustainable capacity building, rather than direct service
provision: key objectives and values must be jointly agreed and written into contracts
• NGOs with consistently poor performance must be reviewed and the issues addressed
• Donors must underpin this accountability between NGOs and health services and act as enablers

18. In order to do that….
• Better coordination and learning
• Need to learn better as a group – often internally incoherent in policies
• More reflection and understanding of the drivers of change in institutions
• Reduce staff turn over
• Build capacity in-country
• Built better institutional memory

19. Do no harm….
Fundamentally, institutions have to be internally constructed BUT
donors have a duty to not disrupt:
• Not creating parallel structures and power bases
• Not offering salaries that attract all of talent out of core institutions
• Not circumventing mandated decision-makers in MoHS (donors
commonly play off different stakeholders in MoHS)
• Providing funds in a way that does not undermine role of MOHS
(direct to NGOs, with no MoHS oversight etc.)
“The disparities created by salary top-ups and parallel
implementation units (PIU), also donor-created, complicate civil service
reform and may leave a new legacy of public
servants who believe themselves to be specially entitled” (OECD report on
Sierra Leone, 2010)

20. Some references from the group
Wurie, H., Samai, M., Witter, S. (2016) Retention of health workers in rural and urban Sierra Leone: findings from life histories. Human
Resources for Health, 14 (3). http://www.human-resources-health.com/content/pdf/s12960-016-0099-6.pdf
McPake, B., Witter, S., Ssali, S., Wurie, H., Namakula, J. and Ssengooba, F. (2015) Ebola in the context of conflict affected states and
health systems: case studies of Northern Uganda and Sierra Leone. Conflict and Health; 9; 23.
http://www.conflictandhealth.com/content/9/1/23
Bertone, M. and Witter, S. (2015) An exploration of the political economy dynamics shaping health worker incentives in three districts in
Sierra Leone. Social Science and Medicine, volume 141, pp56-63. http://www.sciencedirect.com/science/article/pii/S0277953615300447
Witter, S., Benoit, J-B, Bertone, M, Alonso-Garbayo, A., Martins, J., Salehi, A., Pavignani, E., Martineau, T. (2015) State-building and
human resources for health in fragile and conflict-affected states: exploring the linkages. Human Resources for Health special edition on
investing in HRH. http://www.human-resources-health.com/content/13/1/33
Witter, S., Wurie, H. And Bertone, M. (2015) The Free Health Care Initiative: how has it affected health workers in Sierra Leone? Health
Policy and Planning journal, 1-9.
http://heapol.oxfordjournals.org/content/early/2015/03/21/heapol.czv006.full.pdf?keytype=ref&ijkey=VPzC5PJtxdrYeKa
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.conflictandhealth.com/content/pdf/1752-1505-8-11.pdf
Evidence for supporting a skilled health workforce for all in Sierra Leone. https://rebuildconsortium.com/media/1243/sl-project-2-
briefing-nh-edit-2b.pdf
Universal health coverage amid conflict and fragility: ten lessons from research.
http://globalhealth.thelancet.com/2015/12/14/universal-health-coverage-amid-conflict-and-fragility-ten-lessons-research

21. Thank you
On behalf of ReBUILD consortium
• Institute for International Health and Development (IIHD), Queen Margaret University, UK
• Liverpool school of Tropical Medicine (UK)
• College of Medicine and Allied Health Sciences (CoMAHS), Sierra Leone
• Biomedical Training and Research Institute (BRTI), Zimbabwe
• Makerere University School of Public Health (MaKSPH), Uganda
• Cambodia Development Research Institute (CDRI)
Also to colleagues who contributed ideas and examples, including Maria Bertone, Haja Wurie,
Carole Green, and Sas Kargbo
www.rebuildconsortium.com
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