Unsalaried Healthcare Workers in Sierra Leone – IGHN Conference 2022, 26th October

January 9, 2023

Health Systems and Resilience – COVID 19 – Parallel Session 1

By Filza Masood

Dr Pieternella Pieterse from the DCU School of Nursing, Psychotherapy and Community Health discussed her ongoing research on a very important topic that many of us have are oblivious to; the unsalaried health workers in Sierra Leone. Dr. Pieterse highlighted the effects of their unpaid status on their own well-being, as well as the health services they provide to the community.

Sierra Leone has one of the world’s highest rates of maternal, neonatal, and infant mortality. Cost is a significant barrier to accessing healthcare for women and infants who are entitled to free services. Dr. Pieterse stated that a shocking 50% of healthcare workers are not registered on the payroll and receive no salary. These are full time workers but treated as “volunteers” and given no payment.

We asked Dr. Pieterse how and why people find themselves in the position of an unsalaried health worker. She explained that many graduates of low level medical courses are posted to the roles of unsalaried healthcare workers with the aim to be added to the payroll eventually, but more often than not, this never occurs. The lack of regulation means that there is no control over the health care provided or the prices charged by these workers.

The status of unsalaried health workers in Sierra Leone is severely understudied but Dr. Pieterse stressed the direct impact they are having on the health systems. In 2010, the president of Sierra Leone introduced the Free Health Care Initiative (FHCI) which made healthcare free for pregnant women and children under the age of five. The lack of regulation and difficulty to hold unregistered workers accountable result in informal charging for health services that should be free. This link between unregistered health workers and informal charging has been explored in literature (Enria et al., 2021) but there is still a gap in knowledge and lack of studies available.

As these volunteer health workers are unregistered, they often are left out in standard regulations and protocols such as the distribution of personal protective equipment (PPE). This can result in them becoming more susceptible to acquiring and transmitting infectious diseases to their colleagues and patients (Squire et al., 2017).

There are many consequences associated with operating a health system and only paying half the staff and it is still unclear to what extent the unsalaried workers affect the health system. The research that Dr. Pieterse and her colleagues are doing aims to highlight the causes and consequences of a system where half the health workers are unsalaried and how this affects their own lives and the care they provide within an already vulnerable healthcare system.



Squire JS, Hann K, Denisiuk O, Zachariah R. Staffing in public health facilities after the Ebola outbreak in rural Sierra Leone: How much has changed? F1000Res. 2019 Jun 6;8:793. doi: 10.12688/f1000research.18566.2. PMID: 32148756; PMCID: PMC7047906.

Enria L, Bangura JS, Kanu HM, Kalokoh JA, Timbo AD, Kamara M, Fofanah M, Kamara AN, Kamara AI, Kamara MM, Suma IS, Kamara OM, Kamara AM, Kamara AO, Kamara AB, Kamara E, Lees S, Marchant M, Murray M. Bringing the social into vaccination research: Community-led ethnography and trustbuilding in immunization programs in Sierra Leone. PLoS One. 2021 Oct 22;16(10):e0258252. doi: 10.1371/journal.pone.0258252. PMID: 34679104; PMCID: PMC8535180


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