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Staff recognition and its importance for surgical service delivery: a qualitative study in Freetown, Sierra Leone

  • Willott, Chris1
  • Boyd, Nick1, 2
  • Wurie, Haja3
  • Smalle, Isaac1, 4
  • Kamara, T B4
  • Davies, Justine I5, 6, 7
  • Leather, Andrew J M1
  • 1 King’s Centre for Global Health and Health Partnerships, UK , (United Kingdom)
  • 2 Bristol Royal Hospital for Children, Upper Maudlin Street, UK , (United Kingdom)
  • 3 College of Medicine and Allied Health Sciences, University of Sierra Leone, Sierra Leone , (Sierra Leone)
  • 4 Department of Surgery, College of Medicine and Allied Health Sciences, University of Sierra Leone, Sierra Leone , (Sierra Leone)
  • 5 Centre for Applied Health Research, University of Birmingham, UK , (United Kingdom)
  • 6 Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, South Africa , (South Africa)
  • 7 Centre for Global Surgery, Department of Global Health, Stellenbosch University, South Africa , (South Africa)
Published Article
Health Policy and Planning
Oxford University Press
Publication Date
Nov 27, 2020
DOI: 10.1093/heapol/czaa131
PMID: 33246332
PMCID: PMC7938499
PubMed Central


We examined the views of providers and users of the surgical system in Freetown, Sierra Leone on processes of care, job and service satisfaction and barriers to achieving quality and accessible care, focusing particularly on the main public tertiary hospital in Freetown and two secondary and six primary sites from which patients are referred to it. We conducted interviews with health care providers ( N = 66), service users ( n = 24) and people with a surgical condition who had chosen not to use the public surgical system ( N = 13), plus two focus groups with health providers in primary care ( N = 10 and N = 10). The overall purpose of the study was to understand perceptions on processes of and barriers to care from a variety of perspectives, to recommend interventions to improve access and quality of care as part of a larger study. Our research suggests that providers perceive their relationships with patients to be positive, while the majority of patients see the opposite: that many health workers are unapproachable and uncaring, particularly towards poorer patients who are unable or unwilling to pay staff extra in the form of informal payments for their care. Many health care providers note the importance of lack of recognition shown to them by their superiors and the health system in general. We suggest that this lack of recognition underlies poor morale, leading to poor care. Any intervention to improve the system should therefore consider staff–patient relations as a key element in its design and implementation, and ideally be led and supported by frontline healthcare workers.

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