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How to promote a resilient health workforce in conflict affected settings - insights from four countries

  1. How to promote a resilient heath workforce in conflict affected areas: insights from four countries Chair: Sophie Witter HSG, 18 November 2016 Research for stronger health systems post conflict
  2. Overview • Background on ReBUILD & health worker incentive research • Health workers’ motivation to join the profession (Justine Namakula) • Health workers’ experience of crisis and conflict & how they coped (Haja Wurie) • Health worker’s experiences of incentives and incentive policies post conflict and crisis (Sophie Witter & Yotamu Chirwa) • How health staff manage complex remuneration in fragile and post-conflict settings (Maria Bertone) • Wrap up and overview of resources • Discussion Research for stronger health systems post conflict
  3. Background on ReBUILD Decisions made early post-conflict can steer the long term development of the health system Research for stronger health systems post conflict Post conflict is a neglected area of health system research Opportunity to set health systems in a pro-poor direction Useful to think about what policy space there is in the immediate post- conflict period Choice of focal countries enable distance and close up view of post conflict
  4. ReBUILD research and partnerships Health financing Gender & equity Health workforce Aid effectiveness Contracting models Health systems and resilience Research for stronger health systems post conflict Consortium partners • College of Medicine and Allied Health Sciences (CoMAHS), Sierra Leone • Biomedical Training and Research Institute (BRTI), Zimbabwe • Makerere University School of Public Health (MaKSPH), Uganda • Cambodia Development Research Institute (CDRI) • Institute for International Health and Development (IIHD), Queen Margaret University, UK • Liverpool School of Tropical Medicine (UK) Consortium affiliates working in additional countries: Cote d'Ivoire, Nigeria and South Africa; Sri Lanka, Gaza and Liberia
  5. Background on ReBUILD research on health worker incentives Research tools Cambodia Sierra Leone Uganda Zimbabwe 1. Stakeholder mapping √ √ 2. Document review √ √ √ √ 3. Key informant interviews √ 33 √ 23 + 18 + 19 √ 25 √ 28 4. Life histories with HWs √ 24 √ 23 + 39 +25 √ 26 √ 34 5. Quantitative analysis of routine HR data √ √ √ 6. Survey of health workers √ 310+266 (+logbooks) √ 227 Witter, S., Chirwa, Y., Namakula, J., Samai, M., Sok, S. (2012) Understanding health worker incentives in post-conflict settings: study protocol. ReBuild consortium. summary-health-worker-incentives.pdf Research for stronger health systems post conflict Objective: to understand the evolution of incentives for health workers post-conflict and their effects on HRH and the health sector
  6. Scope and sample sites Cambodia Sierra Leone Uganda Zimbabwe Site selection 6 provinces (covering all 4 ecological regions) 4 districts (covering all main regions) 3 districts in most conflict-affected area 2 provinces – one well served and one under-served Sectors included Public sector only Public sector only 65% public; 35% PNFP (private not- for-profit - largely mission sector) Mixture ranging from the government sector; the municipality; the Rural District Councils, the mission sector and the private sector Time- frame 1999 onwards (post- conflict) 2000 onwards (last phase of conflict; post- conflict since 2002) 2000 onwards (six years during; six years after) 1997 onward (economic crisis, and post- since 2009)
  7. Motivation to join health workforce: learning from four settings Justine Namakula Research for stronger health systems post conflict
  8. Focus • Factors influencing motivation to join • Patterns in expressed motivation to join the profession across different settings and cadres • Linkage between motivation and retention • Implications for HRH policies in the health systems studied
  9. Factors influencing motivation to join Personal calling • Desire to serve communities • Innate caring personality “Reason for choosing this career because I love it and can help people in my community” (Cambodia) “…. it was a calling and feeling of wanting to serve people, so I thought that if I am trained I can also come and save the life of my people” (Uganda)
  10. Family influence • Instruction and advice • Role models • Relatives with health problems “I became a nurse because […] I was also encouraged by my grandfather who was employed at Mashoko Mission Hospital to join the nursing field “ (Zimbabwe) ‘[…] My Mother too wanted me to do nursing […]She made all the arrangements that I should do nursing because she had wanted to do it but she did not do it.. […]that’s what made me to do it[…] (Sierra Leone) Factors influencing motivation to join
  11. Factors influencing motivation to join Status and esteem of health professionals “I learnt that doctor had good income and respect from people in the community. I can also help people” (Cambodia) ‘From the way I saw how the nurses were all well-dressed at that time, the doctors were working efficiently…….. ‘(Sierra Leone) ‘’[...] I could see the nurses fully dressed and very smart. So that is one thing that inspired me mostly. I therefore decided that I should be a nurse and be smart like them’’ (Uganda) ‘ I used to adore nurses in their white uniforms since I was young so I came to train as a nurse in 1995 up to May 1999” (Zimbabwe)
  12. Factors influencing motivation to join Economic factors • Perceived better pay than other professions • Incentives (Uganda) • Means of survival for family (all) • Short training time= money more quickly (Cam) • Scholarships for medical training (SL) Educational background • Science subjects • Flexibility in level of education background • Failure to get medicine [some cadres] Proximity to facilities • For those who joined through volunteering
  13. Policy implications for resilience Recruitment strategies for retention in hard to serve areas should focus on staff with strong intrinsic motivation • key for conflict and crisis (erratic pay, difficult working conditions, non-functional formal promotion structures) [e.g. Ug.] Training policies should focus on offering good access for less advantaged local students • May contribute to strong retention and loyalty to sector Volunteering • should not be ‘abused’ [ e.g. SL]. • also need to ensure quality Consider themes of professional status in policy circles • Uniforms ( SL, Zim, Ug] • Maintain respect [ Ug] • Revive trust in epidemiological crisis [ SL] • Maintain brand image?[ may be costly but also very beneficial]
  14. Effect of conflict & crisis on health workers and coping mechanisms Dr Haja Wurie Research for stronger health systems post conflict
  15. Conflict – Northern Uganda, Cambodia, Sierra Leone • Cambodia • 1969-1978 conflict - Khmer Rouge regime • Devastating effects on social and economic infrastructures and severe HRH implications • 1979: Regime partially overthrown in 1979, but continued conflict in some areas • 1999: reconstruction initiated but challenges for the health system still exist • Northern Uganda • Conflict lasted 20 years (1986-2006) • Negative impact for the broader health system including health workers who stayed • Peace Recovery and Development Plan informed the post conflict recovery phase to improve the general health service delivery • Sierra Leone • Civil war that spanned 11 years ending in 2002 Health care system devastated and its effect still evident a decade after the war
  16. Economic crisis - Zimbabwe • Resulted in the decline of Zimbabwe’s Gross Domestic Product leading to inadequacies to finance government services. • Negative impact on the economy between 2000 and 2008 • Mid-2008, hyper-inflation led to the demonetisation of the Zimbabwe dollar and the adoption of multiple currencies as official tender in 2009 • Decline in living standards and increase in poverty occurred during this crisis period, alongside dramatic decline in health indicators Decade long socio-economic and political crisis between 1997 and 2009
  17. Ebola – Sierra Leone (2014-15) • All efforts made in the post conflict phase suffered a major setback • Outbreak and the response further exposed the gaps in the health sector • Second rebuilding phase underway
  18. Effect of conflict on health workers Personal • Abduction ‘…. I was abducted by rebels in 1993. I was with the rebels up to 1995, and when I gained my freedom..’ (Sierra Leone) ‘…and so the rebels went with the clinical officer to go and tell them which drug works for which infection[...] but he came back after some months…’ (Northern Uganda) • Death and injury ‘My family had 6 members, after Khmer Rouge, only 3 were left. My father was taken for education and never returned. My sister and brother died of malaria’ (Cambodia) • Insecurity and fear “…soldiers coming to hospital for service and when we could not provide them service or medicine as fast as what they wanted, sometime they shot to the air or they threatened us” (Cambodia) “Then you could hear gunshots, someone shooting just very near at times you feel like you are going to be short at that time, that fear was there” (Northern Uganda) Professional • Overload “Also in the PHU the work load was too much, the staff capacity was very low […] initially we were only 3, myself, the CHO, one SECHN and one MCH aide, so we were subjected to work right round the clock… (Sierra Leone) • Challenging working conditions “At the beginning it was terrible. The hospital at Prek Pnov had only one or two beds and there were a lot of patients who got malaria, diarrhoea, and so on. The road was often very bad. It was not really safe, some of the sounding area, Khmer Rouge pass by very often” (Cambodia) • Non-receipt of salary ‘…we lived by magic […] you don’t know when you will get your salary and what you have at home you don’t want it to get finished because there are children […] So we had to manage the finances […] the little we had […] People who had the stuff will hide it because they don’t want it to get finished and what you wanted you are searching all over the place. Even one of our church members lost his life just going out to look for rice and he was shot’ (Sierra Leone)
  19. Effect of economic crisis on health workers • Increased shortages of staff “…there are challenges of shortage of human resources and other materials. We are short staffed; six nurses short, there is need to increase the number of nurses” (Zimbabwe) • Devaluation of pay • Resource shortages at work “There is a shortage of drugs and there are no doctors, it is very difficult to work in those conditions. There is also a shortage of equipment and drugs to use during labour, people endure pain for a long time and at times there will be no driver for the ambulance to transfer the patients to a referral hospital” (Zimbabwe) • Living conditions “Staff accommodation is also a problem - some nurses are staying in boys hostels and there are no cooking facilities and some building have deteriorated but they cannot be renovated because of lack of funds” (Zimbabwe) • Loss of quality and discipline “There is no transparency in the recruitment of students and workers. You will see a husband, wife and children working at the same place. You cannot control behaviour of people with power, they corrupt the situation and they are difficult to manage and supervise” (Zimbabwe)
  20. Effect of Ebola on health workers Personal • Fear of death • Fear of patients • Changed family dynamics “I left home and since then I’ve not been back because I didn’t want to work with patients and go home and if I should fall sick, if its Ebola then my family will have to be in quarantine for 21 days […] this is one sacrifice I have had to make to get separated from my family” • Community stigma “(They were) saying your husband is working there, please don’t get from our (water) well […]So my wife is really stressed by them. I always told her ‘please just be calm, we know we are doing the right thing, let us pray” Professional • Lack of supplies and equipment “You need to have the necessary equipment to fight. What has been the problem is that even when there is this readiness of facing this battle we have not been given the proper equipment to fight.” • Increased stress and workload • Economic difficulties “Many health workers, their basic earning power decreased as a result of Ebola. So it has this economic impact….” • Worsened relationships with colleagues “… colleagues in the general ward they were really intimidating us. If I walked through this corridor, they will just move and just give a space for me to pass.”
  21. Similarities and differences Physical safety (conflict and epidemics) Psycho-social (conflict and epidemics) Working conditions and remuneration (all shocks) Impact of shock on health workers • Death and injury • Infection • Fear for self, family and colleagues • Loss of trust in community, in colleagues, in patients • Disrupted family lives • Stress • Overload • Lack of resources for working and living • Blockages or loss of pay and remuneration • Loss of quality and discipline in the workplace
  22. Coping strategies Physical safety (conflict and epidemics) Psycho-social (conflict and epidemics) Working conditions and remuneration (all shocks) Coping by health workers • Self- protection • Internal values and resources, including religion, patriotism etc. • Personal strategies for distraction, comfort and sedation • Peer support, including through social media • Family support • Additional earning options • Dual practice (mainly in economic crisis) • Borrowing money • Working longer hours • Task shifting and taking on new roles; improvisation to cover material shortages • Informal movements of staff • Using own resources for patients or passing on costs to patients External support • Protective materials provided • Managerial support (local and international) • Workshops and training • Rebuilding relationships with communities • Donor support • Expatriate staff support • Additional allowances (e.g. risk allowance)
  23. Policy implications Working conditions and remuneration • Plans in place for rapid response – e.g. providing back-up drug supplies • More flexible payment systems for staff • Greater freedom for local responses • Redeployment where needed Physical safety • Enforcement of protective laws for health workers during conflict Psycho-social • More proactive communication • Support for health staff and communities in all crises
  24. HRH incentive policies post-conflict and crisis Sophie Witter & Yotamu Chirwa Research for stronger health systems post conflict
  25. Analysing policy evolution across contexts • HRH challenges widely shared across the four cases in the post-conflict period but that the policy trajectories were different – driven by the nature of the conflicts but also the wider context • Problems are well understood in all four cases but core issues – such as adequate pay, effective distribution and HRH management – are to a greater or lesser degree unresolved • These problems are not confined to post-conflict settings, but underlying challenges to addressing them – including fiscal space, political consensus, willingness to pursue public objectives over private, and personal and institutional capacity to manage technical solutions – are liable to be even more acute in these settings. • The role of the MoH emerged as weaker than expected, while the shift from donor dependence was clearly not linear and can take a considerable time • Financial and technical dependence can change at different paces • Windows of opportunity for change and reform can occur but are by no means guaranteed by a crisis – rather they depend on a constellation of leadership, financing, and capacity • Recognition of urgency is certainly a facilitator but not sufficient alone • Evidence of path dependency in decisions made post-conflict • Post-conflict environments face particularly severe challenges to evidence-based policy making and policy implementation, which also constrain their ability to effectively use the windows which are presented
  26. Incentive packages Incentives – need to ensure a balanced package over time, once the intensity of the conflict experience recedes, which prioritises those who serve in hard- to-reach areas but also ensures equity across conflict lines. • Consultation of staff is key in developing these policies; good communication within facilities and within the sector is a ‘low hanging fruit’ • Also reinforcing supervision and improving working conditions • Aspects which require more organisational change can receive less priority than financial incentives, which donors find easier to finance In PC settings, similar motivations for staff and changing aspiration over the career cycle to more stable settings but even greater tendency to fragmentation of incentive structures • Linked to multiple actors? • Incentive policies tend to be piecemeal, poorly funded and implemented • No feedback loops • Policies often crafted with external inputs but limited traction • Some areas of reform particularly hard to address, like management reforms • Some countries experience increased patronage/interference with postings and promotions Phases: fragmentation initially may be adaptive, but when to harmonise (e.g. Timor Leste – on to payroll quite quickly). Also opportunities to learn and innovate - e.g post-Ebola SL; able now to capitalise on interest; use evidence from past.
  27. Mind the (sectoral) gap The conflict/post-conflict dynamics can affect the balance of attraction and retention across sub-sectors within health, distorting the provision of care. • e.g. in northern Uganda, during the conflict, the PNFP sector remained more functional, including in terms of supporting staff with pay. • The public sector was boosted in the post conflict phase due to increased investments under the PRDP, consolidation of allowances and introduction of hard to reach allowances. The salaries also became more regular while pension continued to be provided. • Our findings suggest that retention within the PNFP sector has had to rely on more personal factors, such as loyalty and family ties, while many still working in the PNFP sector express the intention to leave, if circumstances permit. • In Zimbabwe, the public sector has been unable to offer the same terms and conditions for staff, given the crisis; the municipalities have independent income source and so employ more senior staff to do less demanding roles in urban clinics, adding to shortages in other areas
  28. Rural retention Rural health workers face particular challenges, some of which stem from the difficult terrain, which add to common disadvantages of rural living (poor social amenities etc.). • Poor working conditions, emotional and financial costs of separation from families, limited access to training, longer working hours (due to staff shortages) and the inability to earn from other sources make working in rural areas less attractive. • Moreover, rules on rotation which should protect staff from being left too long in rural areas are not reported to be respected. • Incentives for rural areas limited political focus – especially ineffectual? • Insecurity By contrast, poor management had more resonance in urban areas, with reports of poor delegation, favouritism, and a lack of autonomy for staff. Tensions within the team over unclear roles and absenteeism are also significant demotivating factors in general. Local staff & mid-level cadres more likely to work in remote areas During economic crisis, rural areas can have advantages (e.g. Zim – lower costs, able to subsist etc.) To work in remote areas workers need: • recognition of role and achievements in challenging circumstances • practical measures to improve their security • provision of decent housing, working conditions, training and pay • trust, communication and teamwork
  29. The gendered health workforce • Lack of balance: in all contexts women predominate in nursing and midwifery cadres; are under-represented in management positions and tend to be more clustered in lower paying positions • Gender roles, shaped by caring responsibilities at the household level, also affect attitudes to rural deployment and women in all contexts faced particular challenges in accessing both pre- and in-service training as compared to their male counterparts • Conflict and coping strategies within conflict emerged as a key theme, with gendered strategies and experiences also shaped by poverty and household structure • Most HRH regulatory frameworks did not use the PC moment to address gender. Key priority areas for addressing gender equity in the health workforce in FCAS include (1) ensuring gender is integrated into policy and (2) fostering dialogue and action to support change for gender equity within institutions and households. Research for stronger health systems post conflict
  30. Overview of incentive evolution in Zimbabwe • Inability to remunerate health staff effectively since start of crisis • Emergency response from international partners, who contributed to the retention allowances and later critical post allowances, was crucial after the crisis in 2009 • Contributed to a reduction of internal movement of health workers as a result of an improvement in incentives in the post- crisis period (harmonized retention, HTF and RBF) • Dollarisation in the immediate emergence from crisis also contributed to the relative stabilisation of the health workforce • RAA is the only incentive specific to rural areas, but has not been effective because it is universal, low and not related to hardship posts • Senior and experienced health personnel concentrated in PHC facilities (in municipalities) • Insecurity of allowances and debates over who receives them continue… with renewed threat of brain-drain
  31. Salary differentials • Higher salaries in the municipality compared to public and mission subsector (main providers of health care in rural areas) • Nurses and midwives willing to take up positions in the municipal subsector even if they were more senior and qualified because of the higher salaries 32 Cadre Government Municipality Mission Cadre Maximum salary (USD) Maximum salary (USD) Maximum salary (USD) EHP 420 2,700 550 MWs 485 2,200 350 Nurses 434 2,203 400
  32. Comparison of hourly rates of remuneration by sector (2013)
  33. Other benefits, by sector 0% 10% 20% 30% 40% 50% 60% Govt Municipality Mission Govt Municipality Mission Govt Municipality Mission Housing Food Health Care Percentange of cadres who received non- financial benefits by sub- sector 0 20 40 60 80 100 120 140 160 180 Amountin$ Incentives paid by sub-sector in $ Government Municipal Mission
  34. Health workers experiences of different sectors in Zimbabwe Municipal health workers after qualifying I worked at [FBO]at City Health since 1988… I applied …was …interviewed and I passed the interview. …I’m staying here till retirement… I’m getting a very good salary, housing allowance, professional allowance, midwifery allowance, water allowance, transport allowance (IDI 015 female Nurse I applied to the municipality for a job, was interviewed and got the job in 1990 and ever since I have been a nurse in the municipality and I will retire from here in a year’s time (IDI 003Nurse ‘ Public sector I am not happy, am not satisfied because of the salary and the conditions of service. A person in my post must have incentives e.g. car loan, i.e. incentives that make you comfortable (IDI 011 female matron Public sector District 1) Salaries in the public sector were unrealistically low especially during the difficult times…there is some improvement, health workers continue with private work and the question of whether this is sanctioned or not does not arise because the salaries are very low. (KII 22 female Doctor Public sector)
  35. ‘I am managing’: complex remuneration and income use strategies of primary health workers in Sierra Leone Maria Bertone Research for stronger health systems post conflict F O N D A T I O N
  36. Background • Limited evidence on health workers’ actual earnings in post- conflict settings • Formal allowances, but also informal incomes • Is the incentive package is effective in addressing HRH challenges? • How much do primary health workers earn? • What are health workers’ perspectives and views on their incomes? • How do health workers use their incomes?
  37. Methods
  38. Methods (1) • Survey of 266 primary health workers in 198 randomly selected health centres in Bo, Kenema and Moyamba • Different cadres of nurses and nursing aides (CHOs, CHAs & nurses MCH Aides) • Daily logbook completed by health workers over 8 weeks detailing incomes earned and activities performed • 39 in-depth interview with a sub-sample of health workers
  39. Methods (2) Cross-sectional survey Share of user fees Salary Remote Allowance PBF (individual bonus) Salary supplementations / top-ups Per diems Non-health income-generating activities Longitudinal logbook Gifts and payments from patients Sale of drugs and items w/in facility Private practice
  40. Implementation of HRH reforms “They [MoHS at central level] don’t even communicate with us. We are dealing with the staff here, we know the staff movement. [...] But they say that they have the data there. But sometimes they pay staff that are not even in remote areas” (KII – DHMT) “I mean, [PBF] is good in theory, but when it comes nine months later, I think it defeats the whole purpose” (KII – DHTM). “I heard many, many health workers, PHU staff, and DMOs talk about performance-based financing. I've never heard anyone mention this remote area allowance”(KII – NGO). “The real key issue is that with all of these policies and all of these strategies, none of them have been properly operationalised and none of them have stayed around. Like, in 2002, there was a free health care policy announced [...] and then it just didn’t happen. So free health care is announced again in 2010, and it’s like, OK, it’s happening, but is that going to slowly start to fall apart? If PBF is announced, it’s like, oh it comes and then it stops, you know.” (KII – NGO). Remote allowance: 5%-8% of income of all HWs (Dec. 2012)  delayed and then stopped from Jan. 2013 Performance Based Financing: 11% of income of HWs (Sept. 2013)  payments received more than one year later than services are performed Health workers’ incomes
  41. Health workers’ incomes
  42. Health workers’ views of their incomes
  43. Health workers’ views of incomes (1) • Somewhat incongruous accounts on incomes • Importance of non-financial features of incomes: • Entitlement vs. windfall • Ease of access (cash vs. bank) • Fairness and transparency • Delays in payment • Transparency in sharing practices • Income fragmentation as an issue PBF “helps”, “good money”, “really enough” (HWs in all districts). Salary is “not enough”, “is small for the job”, is “not satisfying” (HWs in all districts).
  44. Health workers’ views of incomes (2) • Health workers said that they “manage” “Well, if I gather everything together at the same time it helps [i.e. my income is enough], but the money does not come together, it comes in little bits. So what I have at the moment, I manage with it. I have no other way to do it” (CHA/nurse in Kenema). “I have to manage my life with it [my income]” (MCH Aide in Moyamba) “Well, it is not easy. You have to manage yourself” (CHA/nurse in Moyamba)
  45. Health workers’ use of incomes • Health workers take advantage of the different financial and non- financial features of their incomes  spend different incomes differently • Salary • High and regular (“earmarked”) expenditures • Received through bank account and not readily available • Subject to family pressures • Per diems, non-health activities, in-kind gifts from patients and communities • Personal subsistence while in post+ emergency expenditures • Readily available • Unknown to family (“hidden”) • PBF bonus • Substantial amount which can be re-invested in non-health activities (e.g. business such as buying palm oil, etc.)
  46. Background Policy implications
  47. Policy implications (1) • How generalizable are these findings to other settings? • Formal revenues are the most important income for health workers and essential for their motivation  improve management of official payments • Salary payroll • Remote allowance to improve retention/motivation in rural areas • PBF bonuses • Strengthen routine information system • Decentralize HRH management • Streamline and clarify allowances • Improve transparency and regularity of payments
  48. Policy implications (2) • Non-governmental incomes are also key in the income utilization strategies of health workers Improve incentive packages for health workers • Gather information on the entire remuneration of health workers, including informal incomes, and include them in harmonization efforts (e.g. per diems) • Reflect on the health workers’ perspectives and use of their incomes • Incomes are not fully ‘fungible’  Think of post-conflict/crisis legacies • Income fragmentation due to presence of NGOs (per diems and salary supplementations)? Where? For how long?
  49. Thanks to the whole team and all research participants Cambodia: Sovannarith So, Sothea Sok Sierra Leone: Haja Wurie, Mohamed Samai Uganda: Justine Namakula, Freddie Ssengooba UK: Sophie Witter, Maria Bertone, Alvaro Alonso- Garbayo Zimbabwe: Yotamu Chirwa, Pamela Chandiwana, Wilson Mashange, Mildred Pepukai, Shungu Munyati
  50. Thank you All resources can be found on the ReBUILD website: Contact: @ReBUILDRPC resources-from-rebuild-october-2016.pdf

Editor's Notes

  1. Patterns overtime Whether motivation factors had an influence on loyalty or staying overtime What do these findings imply for policy and resilience?
  2. Family influence directly (advice, instruction) Indirectly through illness Policy implication: Advised against choice, can they be retained? Role models: Those in health profession already/doing health related work. More common for women than men. But Hws also unknowingly acted as role models( poor attitudes=discouragement and good attitudes = desire to pay back to society.
  3. Status/respect based on: Dresscode, way they walked, talked and work ethic. NB: Uniform not mentioned in Cambodia!! Status interwinned with desire for pay.
  4. Environmental health practitioner
  5. Will talk to some of these: these already in the literature vs new ones
  6. increased workload was the most cited. Limited human resources means health workers are over stretched, especially in the provinces, work very long hours and have to be available 24 hours.
  7. Health partners also have helped improve the sustainability of the FHCI by providing equipment/logistics (e.g. motor bikes for health facilities in hard to reach areas) to reach patients quickly and also help develop the infrastructure of health facilities.
  8. The previous presentations looked at why HWs join in, how they cope with conflict, their experiences of different sectors. Here I focus on how HWs treat different income streams differentially and how these insights can feed back into policies on pay and incentives. – in contrast to the other presentations, I focus only on SL.
  9. No doctors, no hospitals
  10. Briefly explain on methods for data collection
  11. Clearly, the salary is the major source of revenue (more than 50%), but it is important to note that per diem payment are the second most important and account for up to 20% of the income. If we look in absolute terms, for example for CHAs and nurses the salary is about 130 USD, while PBF accounts for 20 USD/month and per diems for 50 USD a month + non-health activities = 16 USD + gifts&payments = 13 USD
  12. Is it enough? How to HWs use it?  qualitative analysis
  13. Fairness and transparency: e.g. them or colleagues not receiving salary, remote allowance not clear/not received Entitlement vs. windfall: salary vs. PBF for example (it’s a complement) Delays & transparency in sharing: PBF
  14.  Manage = “get by” but also “actively administer incomes”  (link with next slide)
  15. We found that to “manage” their incomes, HWs use different incomes differently – assign different incomes to different uses.
  16. Generalizability: compare with other countries (e.g. Sophie’s FEMHealth paper). Post-conflict feature?
  17. [notes will be updated] Slide 1: Title slide – with names of team presenting – in order of presentations Introduce team and thanks for We proposed this area of health systems research as we knew – and have subsequently confirmed through our literature reviews – that it was a neglected area of health systems research. The new DFID aid strategy, and those of other donors, has reinforced the importance of this area and we are very pleased to be given the opportunity of sharing our research findings in this important meeting.