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

## TL;DR

This paper examines the growing number of unpaid health workers in Sierra Leone and their impact on healthcare access and financial hardship.

## Contribution

The study provides updated data on unsalaried health workers in Sierra Leone and highlights their role as a 'paradoxical surplus' with limited impact on health coverage.

## Key findings

- Unsalaried health workers outnumber salaried ones in most districts, with over 4000–5000 awaiting payroll inclusion.
- These workers rely on formal and informal income, increasing out-of-pocket health expenses for patients.
- Most unsalaried workers are female auxiliary health workers, trained to a lower cadre.

## Abstract

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.

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.

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.

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.

Sierra Leone's unsalaried health workers have increased in number since 2016Up to 5000 unsalaried clinical health workers are awaiting payroll inclusionThey rely on formal and informal income, driving up out‐of‐pocket health expensesThose awaiting payroll inclusion are predominantly female auxiliary health workers

Sierra Leone's unsalaried health workers have increased in number since 2016

Up to 5000 unsalaried clinical health workers are awaiting payroll inclusion

They rely on formal and informal income, driving up out‐of‐pocket health expenses

Those awaiting payroll inclusion are predominantly female auxiliary health workers