Employed but Unpaid, Volunteers or Paradoxical Surplus? Sierra Leone's Unsalaried Health Workforce.

Background: In 2016, 36.5% of Sierra Leone's health workforce consisted of unsalaried clinical staff whose payroll inclusion was deferred. The Ministry of Health introduced policies to reduce this percentage, renewing pledges to introduce health workforce planning. This paper focuses on how many unsalaried clinical staff currently work in public health facilities, based on a survey among Sierra Leone's District Health Management Teams. The study also draws on qualitative responses from unsalaried health workers regarding their coping strategies.

Methods: A mixed methods approach was used, and this paper reports primarily on the survey conducted among all 16 district health authorities in 2023 and 2024. Findings from qualitative data collected among health workers, salaried and unsalaried, is also reported on.

Findings: 10 out of 16 districts shared staffing data, representing 55% of the population. Just over half of all Peripheral Health Unit clinical staff was unsalaried, and in 7 out of 10 districts those who were unsalaried outnumbered salaried staff. Only the capital Freetown had a large cohort of salaried clinical health workers, 58% in total. The coping strategy information from unsalaried health workers confirmed their financial hardship and formal, and sometimes informal, income generating activities.

Discussion/conclusion: Unsalaried clinical health worker numbers have increased in PHUs since 2016; an estimated 4000-5000 unsalaried clinical staff is in precarious employment, awaiting payroll inclusion. The majority of this 'paradoxical surplus' of health workers is trained to auxiliary cadre, meaning their eventual payroll inclusion will not increase the country's skilled-health-worker-to-population ratio, or improve Universal Health Coverage rates.