Sierra Leone's Health Workforce Crisis: Drivers of Suboptimal Distribution and Poor Retention of Primary Healthcare Workers in Rural Areas

Abstract

Background: Sierra Leone's health outcomes rank among the worst in the world. A major challenge is the shortage of primary healthcare workers (HCWs) in rural areas. HCWs are concentrated in urban areas, and those in rural areas are not retained. This study was undertaken to determine the drivers of distribution, retention, and productivity of rural primary HCWs. Methods: Interviews were conducted with 90 primary HCWs in the public sector, complemented by key informant discussions and review of national policy documents. HCW interviews included: 1) card sort about HCW priorities, 2) questionnaire, 3) semi-structured discussion, and 4) free-listing of challenges and needs. Sampling for HCW interviews was purposive, emphasizing rural HCWs. Results: Among 90 HCWs interviewed, 58 were rural and 32 were urban; 71% of rural HCWs were dissatisfied with their jobs, versus 52% of urban HCWs (p=.01). Rural HCWs were more likely to intend to leave their post than urban HCWs (75% vs. 38%, p=.01). Most (87%) rural HCWs intending to leave wanted to continue with the government but move to an urban location. Job dissatisfaction was correlated with intention to leave (Pearson r=0.77). From the HCW perspective, drivers of poor rural job satisfaction fell into 5 categories: 1) HCWs lacked knowledge of policies, entitlements, and procedures, making it difficult to access their employee rights; 2) HCW remuneration was inconsistent; 3) Rural HCWs lacked essential infrastructure-- motorbikes, electricity, clean water, and housing quarters; 4) Rural HCWs had not received adequate clinical supervision, personal support, and recognition; 5) System-related gaps, e.g. over-centralization of human resource administration, indirectly fueled job dissatisfaction. Discussion: Rural HCWs in this study were dissatisfied and wanted to relocate to urban areas because they were ill-equipped to deliver health services and their quality of life was poor. Poor rural job satisfaction fuels negative health outcomes by causing a shortfall of rural HCWs, and reducing their motivation and productivity. This analysis yielded 18 specific recommendations to overcome drivers of poor job satisfaction in Sierra Leone, which may improve distribution, retention, motivation, and productivity of rural HCWs.