Research for stronger health systems during and after crisis

Sources, determinants and utilization of health workers’ revenues: evidence from Sierra Leone

Maria Paola Bertone1,2 and Mylene Lagarde3

1. Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK; 2. ReBUILD Research Consortium; 3. Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK

Health Policy Plan. (2016) doi: 10.1093/heapol/czw031

This paper investigates the entire set of formal and informal payments available to health workers (HWs) in Sierra Leone, through combined quantitative and qualitative approaches. The paper shows the fragmented nature of remuneration, and heterogeneity in the importance of different income sources. It describes the ways HWs are ‘managing’ in order to ensure their livelihoods and those of their families. The findings have important policy implications for financial incentive strategies.

Key messages from the paper are:

  • This study describes the incomes of primary health workers in Sierra Leone and finds that salaries make up about 60% of the total revenues, while the rest is composed by a variety of formal and informal incomes.
  • Health workers’ narratives reveal that the satisfaction related to the incomes does not depends only on their amounts, but also on non-financial features. Based on these features, health workers choose to assign incomes to different uses.
  • These findings have policy implications for designing incentives as they call for more attention to the earning opportunities for health workers beyond formal allowances, and to the HWs own perspectives which question the assumption of income fungibility.

Full abstract is below, and you can access the paper at Health Policy and Planning here.

Abstract:

Exploring the entire set of formal and informal payments available to health workers (HWs) is critical to understand the financial incentives they face and devise effective incentive packages to motivate them. We investigate this issue in the context of Sierra Leone by collecting quantitative data through a survey and daily logbooks on the incomes of 266 HWs in three districts, and carrying out 39 qualitative in-depth interviews. We find that, while earnings related to the HWs official jobs represent the largest share, their income is fragmented and composed of a variety of payments, and there is a large heterogeneity in the importance of each income source within the total remuneration. Importantly, each income has different features in terms of regularity, reliability, ease of access, etc. Our analysis also reveals the determinants of the incomes received and their level based on individual and facility characteristics, and finds that these are not in line with HRH policies defined at national level. Additionally, from their narratives, it emerges that HWs are ‘managing’, in the sense both of ‘getting by’ and of enacting financial coping strategies, such as mental accounting (spending different incomes differently), income hiding to shelter it from family pressures, and re-investment of incomes to stabilize overall earnings over time, in order to ensure their livelihoods and those of their families. These strategies question the assumption of fungibility of incomes and the neutrality of increasing or regulating one rather than another of them. Together, our findings on earning and income use patterns have important policy implications for how we go about (re)thinking financial incentive strategies.