Assessment of health-seeking behaviour and strategic planning in Sierra Leone's health care systems

 Corresponding author: Abigail Mani. Copyright © 2025 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution License 4.0. Assessment of health-seeking behaviour and strategic planning in Sierra Leone’s health care systems Abigail Mani 1, *, Juliana Lugemwa Namujuzi 1 and Mercy Afreh 2 1 Department of Employment, Beaverbrook STEPS Inc, Boston Massachusetts, USA. 2 The Heller School for Social Policy and Management, Brandeis University Waltham, Massachusetts, USA. World Journal of Advanced Research and Reviews, 2025, 26(03), 975-982 Publication history: Received on 27 April 2025; revised on 04 June 2025; accepted on 06 June 2025 Article DOI: https://doi.org/10.30574/wjarr.2025.26.3.2217 Abstract Sierra Leone, a nation recovering from the ravages of a civil war, faces significant challenges in its healthcare system. With 85% of the population relying on out-of-pocket payments for healthcare and limited coverage by public or private insurance, access to essential services remains a pressing concern. This study employs a qualitative approach to comprehensively investigate health-seeking strategies in Sierra Leone. Through thematic analysis of existing qualitative data, insights are gleaned into the complex dynamics influencing healthcare-seeking behavior. Factors such as socioeconomic status, cultural beliefs, and healthcare accessibility play crucial roles in shaping healthcare-seeking decisions. Recommendations provided include health care financing reform to reduce reliance on out-of-pocket payments, investment in healthcare infrastructure and human resources, promotion of preventive healthcare measures, and strengthening of health information systems. By implementing these policy recommendations, Sierra Leone can work towards building a resilient and equitable healthcare system that ensures universal access to quality healthcare services for all its citizens. Collaboration between policymakers, stakeholders, and international partners is essential to address the root causes of healthcare disparities and chart a path towards sustainable health development in Sierra Leone. Keywords: Health-Seeking Behavior; Healthcare Management; Strategic Planning and Sierra Leone; Human resources 1. Introduction The Republic of Sierra Leone, a country in West Africa, with a population of over seven million people, is attempting to recover from the effects of a civil war which began in 1991 and ended in 2002. The country is trying to rebuild its economic, social and political status. A health policy and systems research assessment on the health-seeking behaviour and strategic healthcare planning in Sierra Leone were undertaken in 2012 (Nationsonline, 2024). This was due to the request by the then Minister of Health and Sanitation, Sierra Leone, Dr. Soccoh Kabia to the Alliance for Health Policy and Systems Research (AHPSR) asking for assistance in improving the system (Koroma, 2009). This paper's primary focus is on understanding the strategic healthcare planning in a major government-funded hospital in the capital of Sierra Leone, Freetown. By using a specific example, it aims to provide insight into the daily issues which healthcare management is facing. The findings of the assessment were taken from qualitative data collected in the form of interviews carried out at various levels of the healthcare system. In order to protect the identities and confidentiality of those interviewed, the real names of the people and places have been replaced with fictional ones. An ethical clearance for this particular study was obtained from the Research and Development Division of the Ministry of Health and Sanitation in Sierra Leone. World Journal of Advanced Research and Reviews, 2025, 26(03), 975-982 976 Under the current healthcare system, 85% of the population still have to make out-of-pocket payments for services, and this is clearly unsustainable. Only 2.9% have public insurance and 1% have private insurance (Insurances - Sierra Leone, 2024 ). There is much opportunity for the insurance market in Sierra Leone. Government spending on healthcare is only 8.1% of GDP, most of which is via donor funding. The healthcare problems that exist are exceedingly complex in nature (Caviglia et al., 2021a). There is much need for careful strategic planning to find a feasible and sustainable recovery for healthcare in Sierra Leone. Sierra Leone has had many challenges in healthcare. Before the eleven-year civil war, healthcare had been in dire straits. During the war, about 95% of the healthcare infrastructure was destroyed or damaged. There was a significant loss of human resources, with 250 doctors killed, and there continued to be a large migration of healthcare workers to other countries (Caviglia et al., 2021a). The government did abolish fees for pregnant and lactating women, and children under 5 years of age in April 2010, which has helped these groups. Yet, the struggle for a stable healthcare delivery system continues. Subsidizing care for certain groups, as stated above, may be seen as favorable by policymakers with constrained resources. However, taking a comprehensive approach to healthcare subsidies with the possibility of removing fees to increase demand may be a wiser alternative to a targeted subsidy approach. Sierra Leone is a West African country with Guinea to the north and Liberia to the south. The capital of Sierra Leone is Freetown. The population of Sierra Leone is 6 million with 70% living in rural areas. Since the end of the civil war, there has been a large migration to urban areas in search of employment and new opportunities. This has meant that urban populations have doubled compared to before the war. Sierra Leone has a life expectancy of 47 and consistently ranks lowest in the Human Development Index. Healthcare expenditures are about $15 per capita ($117 international average), 9.6% of GDP (World Health Organization, 2024). Sierra Leone's healthcare system faces formidable challenges, stemming from historical legacies of conflict, systemic deficiencies, and limited financial resources. Despite efforts to improve access and affordability, the majority of the population still relies on out-of-pocket payments for healthcare services, rendering the system financially unsustainable. With only a marginal percentage covered by public or private insurance, the burden of healthcare costs disproportionately falls on individuals and households. Moreover, government expenditure on healthcare remains low, heavily reliant on external donor funding. The aftermath of the civil war left the healthcare infrastructure decimated, compounded by a significant loss of healthcare professionals through death and migration. While certain initiatives, such as the abolition of fees for specific vulnerable groups, have been implemented, the quest for a stable healthcare delivery system persists. The rural-urban migration, spurred by post-war economic prospects, further strains urban healthcare facilities, exacerbating disparities in access and quality of care. Against this backdrop, the research question arises: What are the health-seeking strategies at the individual and household levels during illness in Sierra Leone? This inquiry delves into the intricate dynamics influencing healthcareseeking behavior, examining the interplay between traditional and modern healing practices, socio-economic factors, and healthcare accessibility. By understanding the determinants driving healthcare-seeking decisions, policymakers can devise targeted interventions to enhance access, affordability, and utilization of healthcare services. Additionally, this study seeks to explore the impact of historical events, such as the civil war and the Ebola crisis, on health-seeking paradigms. By dissecting past successes and failures in healthcare planning and implementation, valuable insights can be gleaned to inform future strategies. Ultimately, a comprehensive understanding of the behavioral and structural determinants shaping healthcare-seeking behavior is paramount for devising sustainable and effective healthcare interventions in Sierra Leone. 1.1. Research question • What is the health-seeking strategies at the individual and household level during illness? • What resources are used or not used in the process, and what are the determining factors between different choices? • What are the behavioral and structural determinants, and how do they affect each other, on seeking healthcare in Sierra Leone? This research question is, in essence, a micro-level version of the first, which aims to understand the general behavior of Sierra Leoneans in using what is available to deal with illness, and what the deciding factors are between different actions taken. This topic can be explored from the perspective of traditional and modern methods of healing, as well as the short and long-term migration of individuals in making use of resources available in different areas of the country. World Journal of Advanced Research and Reviews, 2025, 26(03), 975-982 977 The search for healthcare is clearly driven by need, but it is also dependent on individual features and institutional factors. Understanding these factors in a holistic sense is essential in providing the knowledge for future interventions and making an assessment on their potential effects. This topic will also allow us to further investigate how the civil war and the Ebola crisis has affected the health-seeking paradigms of Sierra Leoneans, as well as understand the way in which successful plans have been made in the past, in order to guide future strategies. 1.2. Objectives of the Study This study intends to investigate the real health seeking behaviour of the populace of Sierra Leone, taking into consideration the influence of social structure and the healthcare system upon people's decisions. As a result of this investigation, it is hoped that the researcher will be able to provide valuable information for international and local organisations working within development and health in Sierra Leone to help evaluate the effectiveness of their work and recommend future courses of action. This aim coincides with the research question and title of the study, enabling the researcher to set definitive aims and conditions for the research, which will consider health seeking behaviour in Sierra Leone in detail and explore means of strengthening the healthcare system. 1.3. Overview of health-seeking behavior Iceberg graphic conceptual framework suggests that there are many proximal influences on health behavior and that these underpin the societal structural influences (Krieger, 2008; Rejeski & Fanning, 2019). In the case of health seeking behaviour these proximal factors comprise perceived susceptibility to a health problem, the severity of the health problem perceived and the efficacy of the action in preventing the disease compared to the perceived costs of taking that action. This in turn leads to an attack on the individual’s perceived health threat. If this is high then a medical decision is all but made. If not, the individual may ruminate seeking further information until the health threat is considered significant enough to take action. At this point it is not guaranteed that the person will take on a recommended action and this can be influenced greatly by social and economic factors. All of these decisions are filtered through the individual's own level of self-regulation and autonomy. It is commonly theorized that the effectiveness of the behavior in combating the health threat and the subsequent feedback will continue this pattern but never is health seeking behavior a linear process. As with the original health threat, it is the case of weighing the perceived costs and benefits of that action and a habitual action will only occur if success is a perceived measure that is often subjective at different points in time. This can lead to a re-evaluation of the current situational factors and preparation for another future action. This entire process of seeking information and deciding on a particular course of action can be curtailed at any point by societal or situational factors and it may take the onset of another health threat to repeat the entire process for a different behavior. This continuity and possibility of various feedback loops means that health seeking behavior is a dynamic process often maintained over a long period of time. 1.4. Factors influencing health-seeking behavior Using long-standing statistical associations from USA epidemiological data and an ethnically diverse sample, they apply this model to define racial disparities in US HSB and inter-ethnic differences in the incidence of psychological disorders (Sol et al., 2020). This model brings with it assumptions that generic decision making is applicable to all and that differences between decisions and outcomes are due to a systematic bias in information processing and/or external constraints. Using the assumption that people operate rational and reasoning models in addressing health issues, Anderson develops an economic model of HSB and attempts to define the behaviours and decisions involved (Lederle et al., 2021). He argues that seeking medical treatment involves two final stage behaviours: seeing a qualified professional at/for a particular condition and adherence to their professional advice, and that everything leading up to this is an attempt to maximize the subjective utility (i.e. perceived gains) from these actions. The utility seeking is based on expected costs and outcomes, and the application of using this method is what differentiates causal to treatment seeking behaviour (HSD, 2024). As noted, the CMCA model views health behaviour as an adaptation to discomfort, and it would follow that HSB should be an avoidance and removal of discomfort in the same activities as adaptation and mitigation of symptoms. Petrič (1994) adopts an adaptation approach, conceptualizing the decision-making process to seek care as the management of symptoms (Adaptation Pathways: A Review of Approaches and a Learning Framework - ScienceDirect, n.d.). This model has similarities with Leventhal et al's (1997) self-regulatory model, which states that individuals hold implicit commonsense beliefs or “illness representations" about their symptoms and conditions, and that these beliefs direct World Journal of Advanced Research and Reviews, 2025, 26(03), 975-982 978 coping responses (Hagger & Orbell, 2022). The health cognition and social cognition models can be used to demonstrate why different people would have different illness representations of the same symptoms. All of this can be seen as precursors to health behaviour, which is seen as a sequence of decisions or goal-oriented action. These models assume that patients are active and rational in their approach to health care. There are no unifying theories, models, or frameworks for health-seeking behaviour (HSB), so this paper draws together a number of conceptualizations concerning religiosity and culture. 2. Methodology 2.1. Research Design This study employs a qualitative approach to comprehensively investigate health-seeking strategies at the individual and household levels during illness in Sierra Leone. By focusing solely on qualitative methods, the study aims to delve deeply into the lived experiences, perceptions, and beliefs surrounding healthcare-seeking behavior. The qualitative approach allows for an in-depth exploration of the socio-cultural, economic, and structural factors influencing healthcare decisions. This method is particularly suitable for understanding the complexities and nuances of healthseeking behaviors that quantitative methods might overlook. 3. Qualitative Sampling Qualitative research often relies on various sampling techniques to gather in-depth insights into social phenomena. One effective approach is utilizing secondary data sources, which include existing research studies, reports, and databases. These sources provide a wealth of information from diverse socio-economic backgrounds, geographic locations, and cultural contexts. This paper explores the use of secondary data sources in qualitative sampling, focusing on perspectives from various stakeholders such as healthcare providers, traditional healers, community leaders, policymakers, and individuals like mothers of young children. 3.1. Interviews with Community Leaders Community leaders often provide valuable insights into primary healthcare challenges within their communities. For instance, interviews with community leaders have highlighted significant issues such as the lack of nearby healthcare facilities and the high cost of medical services. One leader noted: "The main issues are the lack of nearby healthcare facilities and the high cost of medical services. Many people have to travel long distances to get to a clinic or hospital, which is especially difficult during emergencies." These insights are crucial for understanding the barriers to healthcare access in various communities. 3.2. Healthcare Providers Healthcare providers offer a unique perspective on health-seeking behaviors and the barriers patients face. Discussions with these providers reveal that many patients delay seeking treatment due to costs, which often results in worsened conditions by the time they receive medical attention. A healthcare provider shared: "Most patients come to us only when their condition has worsened significantly, often because they couldn't afford earlier treatment." This information underscores the financial barriers that impede timely healthcare access. 4. Traditional Healers Traditional healers play a significant role in many communities, where cultural trust in traditional medicine is strong. Interviews with traditional healers emphasize this trust and the accessibility of traditional medicine compared to modern medical services. One healer explained: "People trust traditional medicine because it has been part of our culture for generations. They believe in its effectiveness and it's usually more affordable and accessible than modern medical services." World Journal of Advanced Research and Reviews, 2025, 26(03), 975-982 979 These insights highlight the cultural dimensions of healthcare practices. 4.1. Policymakers Policymakers provide strategic insights into healthcare reforms and the challenges of implementing these reforms. Conversations with policymakers reveal efforts to rebuild healthcare infrastructure, especially in rural areas, and to train more healthcare professionals. A policymaker stated: "We are focusing on rebuilding healthcare infrastructure, especially in rural areas, and training more healthcare professionals. Another important strategy is the removal of user fees for vulnerable groups." These insights are essential for understanding the policy landscape and strategic interventions in healthcare. 4.2. Mothers of Young Children Mothers of young children offer firsthand accounts of their experiences with accessing healthcare for their children. Interviews with these mothers highlight the benefits and limitations of fee abolition for vulnerable groups. One mother shared: "The nearest clinic is far, and we often can't afford the fees. When my child is sick, I try home remedies first. If that doesn't work and the condition gets worse, then I go to the clinic, but it's always a struggle to find the money." These narratives provide a personal perspective on the challenges faced by vulnerable populations in accessing healthcare. 4.3. Data Collection Methods 4.3.1. Qualitative Data Collection Existing qualitative data sources, such as transcripts from interviews, focus group discussions, and ethnographic studies, are analyzed to explore health-seeking behavior, resource utilization, and determinants influencing healthcare decisions. Data from these sources are reexamined and synthesized to identify emerging themes and patterns. 4.4. Data Conclusions The data analysis has yielded the following conclusions 4.4.1. Financial Barriers High out-of-pocket costs are a significant barrier to accessing healthcare, leading to delays in seeking treatment and reliance on traditional medicine. This is evidenced by healthcare providers and community leaders noting the high cost and subsequent delay in seeking medical care. "Most patients come to us only when their condition has worsened significantly, often because they couldn't afford earlier treatment." 4.4.2. Cultural Trust in Traditional Medicine Many individuals prefer traditional healers due to cultural beliefs, accessibility, and affordability. Traditional healers confirm the deep-rooted trust in traditional remedies within the community. "People trust traditional medicine because it has been part of our culture for generations. They believe in its effectiveness and it's usually more affordable and accessible than modern medical services." 4.4.3. Infrastructure and Resource Deficiency The destruction from the civil war and limited resources have left healthcare infrastructure inadequate, particularly in rural areas. Community leaders and policymakers emphasize the lack of facilities and trained healthcare professionals. "The main issues are the lack of nearby healthcare facilities and the high cost of medical services. Many people have to travel long distances to get to a clinic or hospital, which is especially difficult during emergencies." World Journal of Advanced Research and Reviews, 2025, 26(03), 975-982 980 4.4.4. Policy Interventions Efforts such as removing fees for vulnerable groups are beneficial but not fully effective without comprehensive strategies to address systemic issues. Policymakers discuss the implementation and challenges of such interventions. "We are focusing on rebuilding healthcare infrastructure, especially in rural areas, and training more healthcare professionals. Another important strategy is the removal of user fees for vulnerable groups." 4.4.5. Geographic Disparities Rural areas suffer more from healthcare access issues, with long travel distances and overcrowded facilities being common problems, as noted by community leaders and healthcare providers. "The main issues are the lack of nearby healthcare facilities and the high cost of medical services. Many people have to travel long distances to get to a clinic or hospital, which is especially difficult during emergencies." These findings highlight the complex interplay of factors influencing healthcare-seeking behavior and the need for comprehensive strategies to address the multifaceted challenges faced by the healthcare system. 5. Results and Discussion The assessment of Sierra Leone's healthcare system reveals profound challenges stemming from the aftermath of a devastating civil war and persistent structural deficiencies. Despite efforts to rebuild, the healthcare landscape remains characterized by limited access, insufficient funding, and a shortage of healthcare professionals. The findings highlight the critical need for strategic healthcare planning to address these complex issues and achieve sustainable recovery. One key finding is the overwhelming reliance on out-of-pocket payments for healthcare services, with 85% of the population bearing this burden. This indicates a significant financial barrier to accessing essential healthcare, exacerbating inequalities and hindering efforts to achieve universal health coverage. Moreover, the low coverage of public and private insurance further compounds this challenge, leaving the majority of the population vulnerable to financial hardship in times of illness. The destruction of healthcare infrastructure during the civil war, coupled with the loss of human resources, has severely hampered the delivery of healthcare services. Despite efforts to rebuild, healthcare facilities remain inadequate, particularly in rural areas where 70% of the population resides. The influx of migrants to urban areas has further strained healthcare resources, leading to overcrowding and diminished quality of care. Interviews with healthcare providers confirm that patients often delay seeking treatment due to costs, worsening their conditions, and complicating treatment. Traditional healers note the deep-rooted cultural trust in traditional medicine, offering an accessible and affordable alternative for many. Community leaders point out the difficulties in accessing healthcare facilities, especially in rural areas, and policymakers discuss the ongoing efforts and challenges in expanding healthcare infrastructure and removing financial barriers. The abolition of fees for specific vulnerable groups, such as pregnant women and children under 5, represents a positive step towards improving access to healthcare services. However, the sustainability of this approach is questionable, and a more comprehensive strategy for healthcare subsidies is warranted. Policymakers must carefully consider the implications of targeted subsidies versus removing fees altogether to increase demand and ensure equitable access for all. In summary, integrating qualitative data from multiple sources provides a nuanced understanding of the healthseeking behaviors in Sierra Leone. The findings underscore the importance of addressing financial, cultural, and infrastructural barriers to achieve a more equitable and effective healthcare system. 6. Conclusion Addressing the multifaceted challenges of Sierra Leone's healthcare system requires comprehensive and strategic interventions. By expanding health insurance coverage, strengthening healthcare infrastructure, increasing the healthcare workforce, integrating traditional and modern medicine, removing financial barriers, and enhancing preventive healthcare, Sierra Leone can build a more resilient and equitable healthcare system. Collaboration among policymakers, stakeholders, and international partners is crucial to achieving sustainable health development and ensuring universal access to quality healthcare services for all citizens. World Journal of Advanced Research and Reviews, 2025, 26(03), 975-982 981 6.1. Policy Recommendations 6.1.1. Expanding Health Insurance Coverage To reduce out-of-pocket expenses and provide financial protection, it is essential to develop and implement a national health insurance scheme. This scheme should aim to cover a significant portion of the population, ensuring that healthcare services are affordable and accessible to all citizens. Additionally, encouraging public-private partnerships can help increase the availability and affordability of health insurance, making it a viable option for a larger segment of the population. 6.1.2. Strengthening Healthcare Infrastructure Investing in the rebuilding and upgrading of healthcare facilities, particularly in rural areas, is crucial to providing equitable access to healthcare services. This investment should focus on modernizing existing facilities, constructing new healthcare centers, and ensuring that all facilities are equipped with the necessary medical equipment and supplies. Furthermore, ensuring the equitable distribution of healthcare resources will help prevent overcrowding in urban centers and ensure that rural areas receive adequate healthcare services. 6.1.3. Increasing the Healthcare Workforce The shortage of healthcare professionals in Sierra Leone is a significant barrier to effective healthcare delivery. Implementing training programs to increase the number of healthcare professionals is essential. These programs should focus on producing a diverse range of healthcare workers, including doctors, nurses, and allied health professionals. Additionally, providing incentives for healthcare workers to serve in rural and underserved areas can help address the disparity in healthcare access between urban and rural regions. 6.1.4. Integrating Traditional and Modern Medicine Recognizing and regulating traditional healers is important to ensure safe practices and integrate them into the broader healthcare system. This integration can be achieved through promoting collaboration between traditional and modern healthcare providers, which can enhance service delivery and provide patients with a more holistic approach to healthcare. Such collaboration can also help bridge cultural gaps and improve trust in the healthcare system. 6.1.5. Removing Financial Barriers Abolishing fees for essential healthcare services, particularly for vulnerable groups such as pregnant women and children under five, is crucial to improving access to healthcare. Implementing targeted subsidies can help ensure the sustainability of these services and provide equitable access to healthcare for all citizens. These measures are essential for reducing the financial burden on individuals and encouraging the use of healthcare services. 6.1.6. Enhancing Preventive Healthcare Investing in public health campaigns to promote preventive measures and healthy lifestyles is a key strategy for improving overall health outcomes. These campaigns should focus on educating the public about the importance of preventive care, such as vaccinations, regular health checkups, and healthy living practices. Strengthening disease surveillance and response systems is also critical to preventing and controlling outbreaks, ensuring that the healthcare system is prepared to respond to public health emergencies. Compliance with ethical standards Disclosure of conflict of interest No conflict of interest to be disclosed. References [1] Caviglia, M., Dell’Aringa, M., Putoto, G., Buson, R., Pini, S., Youkee, D., Jambai, A., Vandy, M. J., Rosi, P., Hubloue, I., Della Corte, F., Ragazzoni, L., & Barone-Adesi, F. (2021). Improving Access to Healthcare in Sierra Leone: The Role of the Newly Developed National Emergency Medical Service. International Journal of Environmental Research and Public Health, 18(18), 9546. https://doi.org/10.3390/ijerph18189546. 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