Health Policy and Planning
Volume 31 Issue 1 February 2016
http://heapol.oxfordjournals.org/content/current

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Original Articles
Editor’s Choice: The free health care initiative: how has it affected health workers in Sierra Leone?
Sophie Witter, Haja Wurie, and Maria Paola Bertone
Health Policy Plan. (2016) 31 (1): 1-9 doi:10.1093/heapol/czv006
Abstract
There is an acknowledged gap in the literature on the impact of fee exemption policies on health staff, and, conversely, the implications of staffing for fee exemption. This article draws from five research tools used to analyse changing health worker policies and incentives in post-war Sierra Leone to document the effects of the Free Health Care Initiative (FHCI) of 2010 on health workers.
Data were collected through document review (57 documents fully reviewed, published and grey); key informant interviews (23 with government, donors, NGO staff and consultants); analysis of human resource data held by the MoHS; in-depth interviews with health workers (23 doctors, nurses, mid-wives and community health officers); and a health worker survey (312 participants, including all main cadres). The article traces the HR reforms which were triggered by the FHCI and evidence of their effects, which include substantial increases in number and pay (particularly for higher cadres), as well as a reported reduction in absenteeism and attrition, and an increase (at least for some areas, where data is available) in outputs per health worker. The findings highlight how a flagship policy, combined with high profile support and financial and technical resources, can galvanize systemic changes. In this regard, the story of Sierra Leone differs from many countries introducing fee exemptions, where fee exemption has been a stand-alone programme, unconnected to wider health system reforms. The challenge will be sustaining the momentum and the attention to delivering results as the FHCI ceases to be an initiative and becomes just ‘business as normal’. The health system in Sierra Leone was fragile and conflict-affected prior to the FHCI and still faces significant challenges, both in human resources for health and more widely, as vividly evidenced by the current Ebola crisis

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Developing a holistic policy and intervention framework for global mental health
Akwatu Khenti, Stéfanie Fréel, Ruth Trainor, Sirad Mohamoud, Pablo Diaz, Erica Suh, Sireesha J Bobbili, and Jaime C Sapag
Health Policy Plan. (2016) 31 (1): 37-45 doi:10.1093/heapol/czv016
Abstract
Introduction: There are significant gaps in the accessibility and quality of mental health services around the globe. A wide range of institutions are addressing the challenges, but there is limited reflection and evaluation on the various approaches, how they compare with each other, and conclusions regarding the most effective approach for particular settings. This article presents a framework for global mental health capacity building that could potentially serve as a promising or best practice in the field. The framework is the outcome of a decade of collaborative global health work at the Centre for Addiction and Mental Health (CAMH) (Ontario, Canada). The framework is grounded in scientific evidence, relevant learning and behavioural theories and the underlying principles of health equity and human rights.
Methods: Grounded in CAMH’s research, programme evaluation and practical experience in developing and implementing mental health capacity building interventions, this article presents the iterative learning process and impetus that formed the basis of the framework. A developmental evaluation (Patton M.2010. Developmental Evaluation: Applying Complexity Concepts to Enhance Innovation and Use. New York: Guilford Press.) approach was used to build the framework, as global mental health collaboration occurs in complex or uncertain environments and evolving learning systems.
Results: A multilevel framework consists of five central components: (1) holistic health, (2) cultural and socioeconomic relevance, (3) partnerships, (4) collaborative action-based education and learning and (5) sustainability. The framework’s practical application is illustrated through the presentation of three international case studies and four policy implications. Lessons learned, limitations and future opportunities are also discussed.
Conclusion: The holistic policy and intervention framework for global mental health reflects an iterative learning process that can be applied and scaled up across different settings through appropriate modifications.

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Two decades of maternity care fee exemption policies in Ghana: have they benefited the poor?
Fiifi Amoako Johnson, Faustina Frempong-Ainguah, and Sabu S Padmadas
Health Policy Plan. (2016) 31 (1): 46-55 doi:10.1093/heapol/czv017