A 2007 WHO report outlined that many least developed countries will not meet the United Nations health related Millennium Development Goals because the health workers did not possess the appropriate managerial competencies. The public health care system in Sierra Leone, a Least Developed Country, is implementing a Free Health Care Initiative targeting pregnant women and children under five years. The focus of this study is to determine if the health workers have the right managerial competencies to implement the Free Health Care Initiative by identifying the health workers perceptions on the relevant managerial competencies and the competency gaps. 39 managerial competencies derived from a similar study in South Africa were analysed in health facilities in the Western Health District of Sierra Leone. The qualitative findings showed that clusters of skills related people management, strategic management, tasks, self-management and health delivery were most important to the health workers and personal competency requirements included computing, staff motivation and communication skills. The findings have broader relevance for stakeholders in the public sector healthcare management and quantitative research is recommended across all 12 Health Districts of Sierra Leone for all level of health workers.