ReBUILD is a 6 year £6million research project funded by the UK Department for International Development (DFID)

Path dependency and windows of opportunities – lessons learned on policy-

making in post-conflict settingsThe 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

Funded by

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

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

Initial hypotheses

Longitudinal study to explore the HRH

policy making trajectory in post-

conflict Sierra Leone

2002-2012

Case study Research questions

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 timingand the political space for reform?4. What lessons can be learned?

Starting point for this study

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.

Three phases of HRH policy-making

2009 2010 201220112006 2007 2008

First phase: recovery & early development of

HRH policies

Second phase: launch of

FHCI and related HRH

policiesThird phase: post-FHCI policy-

making

2002-2009 2009-2010 2011-2012

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).

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)

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

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

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

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

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

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

Ph: Maria Paola Bertone