Exit, voice or neglect

Understanding the choices faced by doctors experiencing barriers to leading health system change through the case of Sierra Leone

Bibliographic Data

ID21257892
AuthorsOliver Johnson (0000-0003-4219-4782, King's College London, corresponding author), Foday Sahr (0000-0001-9816-4502, University of Sierra Leone), Nick Sevdalis (0000-0001-7560-8924, King's College London), Ann H Kelly (0000-0003-4658-2133, King's College London)
Year2022
Volume2
Pages100123
Publication date2022-12-01
Peer ReviewedYes
Open AccessYes
TypeARTICLE
VenueSSM - Qualitative Research in Health (JOURNAL)
Journal identifiersISSN: 2667-3215 • E-ISSN: 2667-3215
PublisherElsevier BV (PUBLISHER)
DOI10.1016/j.ssmqr.2022.100123
PMID36531296
OpenAlexW4285040336
LanguageEN
Citations received2
References cited26

This paper presents a study from Sierra Leone that explored the experiences of doctors as they endeavored to improve the health care systems in which they worked. Twenty-eight interviews were conducted with doctors in Sierra Leone, complemented by long-standing experience of national health provision and research by the authors. Drawing on Hirschman's theory of ‘exit, voice and loyalty’, the paper's framework analysis elaborates the doctor's career decisions and choices under systematic political and economic constraints, and in particular, the specter of retribution, including posting to undesirable jobs and withholding of salaries. This retribution was considered a driver of exit by doctors from the system, and few examples were given of doctors successfully advocating for change through advocacy (‘voice’). We suggest that the relevance of Hirschman's theory to this setting is in drawing attention to the critical themes of retribution, opportunity, loyalties, and partial exits, ones often neglected in efforts to reduce emigration of doctors and strengthen their leadership. Ultimately, this paper critiques the overemphasis of mechanistic ‘capacity building’ in global health and recommends that health system strengthening must be viewed as a jointly political as well as technical exercise

Economic Justice · Health care · Neglect · Political science · Politics · Public relations · Retributive justice · Sierra leone · Socioeconomics · Sociology · Global Health and Surgery · Global Health Workforce Issues · Global Maternal and Child Health · Law · Medicine · Nursing