To optimise the distribution and mix of health workers, policy interventions to address their pay and incomes are needed. Fiscal constraints to increased salaries might need to be overcome in many countries, and non-financial incentives improved. These are the conclusions of authors of a Health Policy paper in this week’s Human Resources for Health Special Edition of The Lancet.
Dr David McCoy, Centre for International Health and Development, University College London, UK, and Dr Sara Bennett, WHO, Switzerland, and colleagues described the historical trend in the pay of civil servants in Africa over the past 40 years. They found accurate and complete data scarce – but noted that between 1989 and 1996, real wages for civil servants (including health workers) fell in 26 of the 32 sub-Saharan African countries for which data are available.
Presently, pay structures vary between countries and are often complex. The authors say: “Health workers also commonly use other sources of income to supplement their formal pay. The pay and income of health workers varies widely, whether between countries, by comparison with cost of living, or between the public and private sectors.” Further, the authors notes that large differences in pay between different types of employers can result in an internal brain drain and mitigate against a more appropriate distribution of scarce staff according to need. They call for efforts to bring greater order to the labour market for health workers.
Other issues raised by the authors included irregular payment, with one Zambian survey reporting that 15% of staff had not always received their regular salary payment, with 80% reporting late payments, and 10% reporting they had to pay a so-called expediter’s fee to obtain their salaries. And length of service benefits also seemed to vary widely – in Burkina Faso, pay did not increase with length of service in the public sector; while Ghanaian salaries increased by a factor of 1.7 over the working life of a doctor, and by 3.7 for midwives.
They discuss the dim prospect of government budgets in sub-Saharan Africa increasing due to economic growth, and say: “For these countries, an increase in public-sector employment and pay for health workers would require sustained external or donor financing.”
In conclusion, they note that increased salaries and incomes for public sector health workers are not the only solution to the health workforce crisis in sub-Saharan Africa. They conclude: “Other solutions that need to be implemented concurrently include non-financial incentives to affect the motivation of health workers. Improving job satisfaction and career progression; enhancing working conditions and the quality of supervision; addressing on-the-job safety and security concerns; redressing the unavailability of good schools for children in rural areas; and improving the structure and management of the payroll could all contribute to retention, motivation, and payment of health workers within the public sector, especially in rural regions where staffing problems are most acute.” Further, they call on WHO, The International Labour Organisation (ILO), research funders, and research institutions to urgently generate the data necessary to facilitate more effective and informed policy making.
Dr Sara Bennett, WHO, Switzerland T) +41 22 791 2840 / +41 79 516 4169 E) bennetts@who.int
Dr David McCoy, Centre for International Health and Development, University College London, UK E) d.mccoy@ucl.ac.uk
PDF OF PAPER: http://multimedia.thelancet.com/pdf/press/Salaries.pdf
Journal
The Lancet