Health Policy
Salaries and incomes of health workers in sub-Saharan Africa
David McCoy, Sara Bennett, Sophie Witter, Bob Pond, Brook Baker, Jeff Gow, Sudeep Chand, Tim Ensor, Barbara McPake
Public-sector health workers are vital to the functioning of health systems. We aimed to investigate pay structures for
health workers in the public sector in sub-Saharan Africa; the adequacy of incomes for health workers; the management
of public-sector pay; and the fiscal and macroeconomic factors that impinge on pay policy for the public sector.
Because salary differentials affect staff migration and retention, we also discuss pay in the private sector. We surveyed
historical trends in the pay of civil servants in Africa over the past 40 years. We used some empirical data, but found
that accurate and complete data were scarce. The available data suggested that pay structures vary across countries,
and are often structured in complex ways. 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. 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.
Introduction
The pay and income of health workers affect health care
and health systems in many ways. Pay and income have
been described as hygiene factors1 that affect motivation,
performance, morale, and the ability of employers to
attract and retain staff. When pay is low in absolute
terms, health workers will moonlight to supplement
their incomes by providing health-care services privately,
engaging in other income-earning activities, extracting
informal fees from their patients, or seeking per-diem
payments by attending workshops and seminars.2 The
wider earning power of health workers depends on the
context in which they work; richer urban settings
generally provide opportunities for private practice,
whereas rural regions provide opportunities to
supplement pay with non-financial income such as
locally grown food.
Health workers are also affected by relative differences
in pay and income. Relatively low pay can cause
dissatisfaction and loss of motivation, and cause
migration towards higher earning jobs. The size of the
pay differential between different types of health worker
(eg, doctors and nurses) can also affect morale, working
relationships, and the available mix of cadres. Differences
in pay and income can therefore affect both retention
within countries and distribution of health workers,
whether between urban and rural areas or between the
public and private sector.
Pay for health workers is also an important determinant
of overall health expenditure. In 2006 in Ghana, for
example, when health worker pay and emoluments went
35% over budget, they absorbed 76% of government
spending on health; this left only 6% of the government
budget for non-wage recurrent expenditure once capital
expenditure had been spent.3
Availability of data
Policy debate and discussion about health-worker salaries
and incomes in countries with low and middle incomes
is constrained by insufficient data. In theory, data on
public-sector pay should be readily available from
www.thelancet.com Vol 371 February 23, 2008
government databases, but in practice, such data are
inaccurate, incomplete, unclear, and out of date.4–6 Pay
structures are often complex, consisting of a mix of
salary, various allowances, periodic bonuses, overtime
payments, and other forms of remuneration such as per
diems. Most data exclude non-wage benefits (such as
employers’ contributions to pensions, medical insurance,
and housing); unofficial payments or gifts from patients;
and other income from private sources.
Because data collection is not standardised or
consistent, cross-country comparisons and analyses of
longitudinal trends are difficult. Cross-country
comparisons are also hindered by differences in job
descriptions, roles, and levels of training. Another
difficulty is that data about the average salary of a
particular type of health worker might not reflect
variations in pay for subsets of workers within that grade
(eg, different types of nurses).
Data on health workers who are employed in the
private sector are more scarce than those for government
staff, notwithstanding concerns about the brain drain of
health workers from the public sector.7,8 The heterogeneity
and lack of regulation that characterise this sector in
sub-Saharan Africa complicate data collection. Even if
the commercial private sector is excluded, scores of
non-profit organisations employ health workers under
different terms and conditions of service.
Because of the poor quality of routinely collected data,
we searched recent surveys of health-worker pay and
income in sub-Saharan Africa. We searched Medline,
and the International Monetary Fund (IMF), World
Bank, International Labour Organization (ILO), and
WHO websites. We also consulted expert researchers
and WHO staff. We obtained public-sector data from
two surveys by the Initiative for Maternal Mortality
Programme Assessment (IMMPACT) in Burkina Faso9
and Ghana,10 and from two by the World Bank in
Zambia11 and Nigeria,12 in collaboration with country
governments (table 1). We have also drawn on three
other sources of secondary data from Zambia,13
Ethiopia,14 and Malawi.15
Lancet 2008; 371: 675–81
See Editorial page 623
See Comment page 632
Centre for International Health
and Development, University
College London, UK
(D McCoy DrPh, S Chand MFPH);
Alliance for Health Systems
and Policy Research, WHO,
Geneva, Switzerland
(S Bennett PhD); IMMPACT,
University of Aberdeen, UK
(S Witter MA, T Ensor PhD);
World Health Organization,
Geneva, Switzerland
(B Pond MD); Health GAP,
Northeastern University School
of Law, Boston, MA, USA
(Prof B Baker JD); Queen
Margaret University,
Edinburgh, UK (B McPake PhD);
and Health Economics and
HIV/AIDS Research Division,
University of Kwazulu-Natal,
Durban, South Africa
(J Gow PhD)
Correspondence to:
David McCoy, Centre for
International Health and
Development, University College
London, 30 Guilford Street,
London WC1N 1EH, UK
d.mccoy@ucl.ac.uk
675
Health Policy
Year of survey
Burkina Faso
Ghana
Nigeria
2006
2005
2001
96
374
717
Number of respondents
Sampling
Two rural districts
(Diapaga and Ouargaye)
12 rural and urban
districts in two regions
(Central and Volta)
Zambia
2005
Not stated, but at least 242
252 public primary-care facilities in
two states (Lagos and Kogi, which
are urban and rural, respectively)
171 public facilities including hospitals
and primary care in two urban and
three rural provinces
Data are from references 9, 10, 11, and 12.
Table 1: Sources of survey data
Agricultural Commerce and Clinical
work
petty trade
work
Other
activities
Medical officers
0
30·0%
10·0%
0
0
Community health
officers
8·4%
12·6%
2·5%
6·7%
5·0%
1·7%
14·3%
17·9%
0
10·7%
3·6%
2·1%
Nurses
0
Home health Sale of
service
medicines
Data are from references 12.
Table 2: Supplementation of public-sector pay in Nigeria by different types of health workers
History of public-sector pay and income
Trends in employment and remuneration of civil servants
in sub-Saharan Africa reflect those for government health
workers. In the decade before 1985, numbers of civil
servants in many sub-Saharan African countries grew at
more than 5% every year.16 In Ghana, for example, the civil
service was five times as large in the 1980s as it had been at
independence in 1957,17 and about 30% of all Ghanaian
civil servants worked for the Ministry of Health.
And yet, sub-Saharan Africa has consistently had fewer
central government employees as a proportion of total
population than other regions of the world (1·1% in the
early 1990s compared with an average of 1·3% for
developing countries in Asia and Latin America). At the
same time, countries in sub-Saharan Africa have devoted a
higher proportion of low GDP to pay these workers
(6·7% of GDP in the early 1990s compared with 4·8% in
developing countries in Asia and Latin America).4
High inflation and structural adjustment programmes
reduced real wages in many countries in sub-Saharan
Africa, with the exception of those that were formerly
under French rule. For example, in real terms, the average
civil-service salary in Tanzania in 1985 was only a quarter
of what it had been 10 years earlier.16 When both real and
nominal civil-service wages decreased, the value of benefits
such as housing and transportation assumed a more
important role. In Senegal, non-wage benefits increased
from 25% in 1980–85 to 43% in 1989 as a proportion of
total compensation for civil servants.16
Another feature of this period was so-called wage
compression, in which proportionately higher nominal
wage increases were awarded to lower-level employees,
thus reducing the ratio between the salaries of the most
qualified and senior staff and the salaries of less qualified
staff.18 In Zambia, the ratio between the salary of an
undersecretary and that of the lowest-paid salaried
676
employee was 19 to one in 1970, and fell to seven to one
in 1983.19 Progressively worse salary compression
“eventually leads to loss of employees with options, i.e.,
the better employees” and “difficulty in recruiting
qualified outsiders, and a ‘deskilled’ workforce too poorly
paid to resist temptation.”4
In the late 1970s and early 1980s, government wage bills,
and health wages in particular, contributed to large fiscal
deficits. Such deficits became unsustainable for many countries and led to structural adjustment in the 1980s and 1990s,
which aimed to get countries to pay their debts and balance
their books. Reforms included freezes on hiring; cessation
of pay increases linked to inflation; elimination of automatic
promotions; voluntary and compulsory retirement; and
removal of “ghost workers” from the payroll.18–23
Between 1986 and 1996, real wages for civil servants fell
in 26 of the 32 sub-Saharan Africa countries for which data
are available.16 Real wages fell most precipitously in the
formerly French colonies after their currency was devalued
by 50% in 1994. In Nigeria, from 1980 to 1993, the official
monthly wage of senior civil servants in constant
1995 international dollars (adjusted for purchasing power)
dropped from US$820 to US$234.24 Nine countries also
lowered non-wage benefits, although five countries
managed to raise them.16
At least 21 countries resorted to retrenchment of some
civil servants.16 The number of civil servants decreased,
especially in Uganda and francophone countries. In
Uganda, the number of civil servants dropped from 320 000
in 1989 to around 148 000 by 1997.25 Of 22 countries for
which data exist, the proportion of civil-service employees
in the population decreased either “sizeably” or “moderately” in all but one country between 1986 and 1996.18
Civil-service reforms during this period of structural
adjustment (1980–90s) typically failed to counter wage
compression. The governments of Ghana, Mozambique,
and Uganda were exceptions; they adopted specific
measures to decompress wage structures as part of their
civil-service reforms.4 For example, in Uganda,
retrenchments combined with increased donor funding
and some economic growth permitted civil-service wages
to be decompressed and increased on average by more
than nine-fold in real terms between 1990 and 1996.
What has been the trend in government employment
and wages over the past ten years? The IMF has tracked
government expenditures on employment for the
www.thelancet.com Vol 371 February 23, 2008
Health Policy
Private income
Per diems
Share of user fees
Allowances
Salary
1200
800
Allowances
Salary
1400
1200
1000
800
600
400
200
600
0
Do
ct
or
Ph
ar
bo
m
ra
a
c is
to
ry
t
sc
ien
tis
t
Tu
t
Se
or
ni
or
nu
rse
Nu
rse
M
id
La
w
C
lin
ife
bo
i
ra
to cal o
ry
ffi
te
ce
ch
r
Ph
no
ar
lo
m
gi
ac
st
yt
ec
hn
ic i
an
Monthly income (US$)
1000
1600
Monthly income (US$)
1400
400
La
200
0
Doctor
Medical
assistant
Midwife
Nurse
Community
nurse
Figure 1: Monthly income for health workers in the public sector in Ghana in
2005 (US$)
Data are from reference 10.
41 countries that they supported with Poverty Reduction
and Growth Facility loans.26 Their data show that in 2005,
the average government wage bill in sub-Saharan Africa
was 6·6% of GDP, which is roughly the same as it was
during the early 1990s. This was lower than in Central
America (11%) but higher than Central Asia (3·7%) and
Asia (4·6%).
Structure and sources of pay
Public-sector pay is commonly composed of different
elements, with basic salary a small component of overall
pay. The Ghana survey, for example, showed that in 2005,
only 26% of a doctor’s monthly income was basic salary,
compared with 43% of that of mid-level workers such as
medical assistants (figure 1).8,10 Allowances (of which an
allowance for additional hours of duty was the largest)
contributed more to total income than did salary. The
Zambia survey also showed the importance of allowances
(figure 2), which constituted nearly 40% of doctors’
incomes from government.11
Therefore, allowances decompress the salary scale across
the workforce. Compared with the salary of a community
nurse, a doctor’s salary in Ghana was three times higher
and their income was four times higher.10 Similarly, in
Zambia, allowances meant that doctors were paid about
four times more than nurses or midwives.11
The large difference in pay between doctors and other
skilled clinical staff such as medical assistants, clinical
officers, and senior nurses highlights the importance of
pay to sector-wide HR planning and getting the right mix
of types of health workers.
The survey data from Burkina Faso neither disaggregated
basic salary income from allowances, nor captured data for
doctors (figure 3).7,9 However, it did reveal that per diems
for attending workshops and training events accounted for
about 10% of total income, and that user fees were another
important source of supplementary income.
www.thelancet.com Vol 371 February 23, 2008
Figure 2: Monthly income for health workers in Zambia in 2005 (US$)
Data are from reference 11.
The surveys reported that income from private practice
made up only 0·1% of the earnings of health workers in
the public sector in Ghana, and close to zero in Burkina
Faso.9,10 However, these figures probably reflect
under-reporting, since in Burkina Faso, only 32% of survey
respondents said they would agree to a new contract to
outlaw private practice; more said they would accept such a
contract only if their public salary was doubled.9
In the Nigerian survey, 45% of staff reported that they
supplemented their income privately (table 2).12 The
Zambian survey also reported that many health workers
had generated income by other activities; this was more
common in urban than rural health centres (32% and
9% of staff, respectively).11 These surveys did not calculate
the monetary value of benefits such as free housing or
transport.
The adequacy of pay
Policy makers need to be able to judge the adequacy of pay
to assess to what extent it contributes to the bad distribution,
poor retention, and low motivation of public sector health
workers. One way is to compare pay against a measure of
the cost of living (table 3).
However, since prices of goods and services vary over
time, and in different parts of a country, and the basket of
services and goods selected to estimate the cost of living
might not always be easily comparable between countries,
the cost of living is not easy to measure.
The calculation of purchasing power parity is based on
an exchange rate that equalises the value of comparable
market baskets of goods and services between countries.
Although purchasing power parity has limitations, it is
seen as the best available method by which to compare
incomes and prices between countries.
Another approach is to benchmark the salaries of health
workers against the average gross national income (GNI)
per person. In Ghana, in 2005, nurses earned nearly
11 times as much as the GNI per person, whereas doctors
earned about 32 times the GNI per person.10 By contrast,
the average government salary was four times the GNI per
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Health Policy
3000
estimated Ghanaian doctor’s salary of US$14 600,
although the real disparity is smaller when cost of living
is taken into account.
Another way to judge the adequacy of pay for health
workers in the public sector is to compare it to pay in the
private sector. In Ethiopia, concern has arisen that
government and university salaries did not match those in
the donor and non-government sector. For example, a
driver for a US bilateral agency in Addis Ababa was paid
more than a professor in the medical faculty, and a
government public-health specialist could earn four to five
times more by joining an international non-governmental
organisation (NGO) (table 4).14
In Zambia in 2004, private health facilities paid much
higher salaries than did the government or NGOs.13 Private
doctors’ salaries were more than double those of
government doctors; midwives’ salaries were almost a
third higher; and laboratory technicians’ salaries were
more than three times those in government. NGOs paid
between 23% and 46% more than the government. The
study also showed that the private sector used incentive
payments, which were as much as 52% of a year’s salary
for one group of private-sector doctors (table 5).13
However, employment in the private sector does not
automatically mean a higher total income. In fact
respondents from the Burkina Faso survey mentioned
that one of the reasons for remaining in the public sector
was that it provided a good salary.9 The survey from Ghana
also showed that midwives who worked in private clinics
had lower incomes than their public-sector counterparts,
although this could have been because the respondents
were often retired individuals who did not work full
time.10
In Malawi, a survey of NGOs in 200515 showed that the
average salaries paid by international NGOs were higher
than salaries paid by local NGOs (eg,US$43 162 per year
and US$29 231 per year, respectively for nurses). Expatriate
Income from gifts
Income from per diems
Income from user charges
Salary and allowances
Annual income (US$)
2500
2000
1500
1000
500
0
Auxiliary
midwife
Outreach
health
worker
Statecertified
nurse
Stateregistered
nurse
Village
midwife
Stateregistered
male
midwife
Stateregistered
female
midwife
Figure 3: Annual income for health workers in Burkina Faso in 2005 (US$)
Data are from reference 9.
person. In Zambia, doctors earned forty times the GNI per
person.11 In both Zambia and Burkina Faso, registered
midwives received more than six times the average GNI,
whereas auxiliary midwives in Nigeria earned about eleven
times the average GNI.9,12 This measure also allows some
cross-country comparisons: the pay of a public-sector nurse
varied from about five times the GNI per person in Burkina
Faso to about 11 times in Ghana.9,10
Table 3 shows that if salaries were simply converted to
US dollars with official exchange rates, doctors from
Ghana would seem to earn less than doctors from Zambia.
However, conversions according to purchasing power
parity suggest that doctors in Ghana earn more than their
counterparts in Zambia.
Although doctors’ incomes were higher than those of
other health workers and the rest of the population,
they were low by international standards. For example,
a family doctor in the UK gets paid more than
US$200 000 per year, which is more than 13 times the
Ghana (2005)
Burkina Faso (2006)
Zambia (2005)
US$
US$
PPP
17 208
31 663
··
4128
7596
5760
12 557
4128
7596
5097
11 113
US$
PPP
PPP
Doctor
14 616
35 648
Midwife
5580
13 610
2873 (male)
2443 (female)
7556 (male)
6426 (female)
Nurse
4896
11 941
2454 (registered)
1871 (certified)
6454 (registered)
4921 (certified)
Nigeria (2001)
US$
PPP
Annual pay
··
··
··
Ratio of salary to GNI per capita
Doctor
32·5
··
··
··
40·0
··
··
··
Midwife
12·4
··
6·7/5·7
··
9·6
··
11·1
··
Nurse
GNI per person
10·9
450
··
1093
5·7/4·4
430
··
1131
9·6
430
··
791
9·8
520
··
1134
PPP=purchasing power parity. GNI=gross national income. Data are from references 9, 10, 11, and 12. Burkina and Nigeria data are inflated or deflated from survey date to
2005 prices. PPP conversions made at 2005 rates using World Bank conversion rates. Figures include all monetary allowances, including income from per diems and local fee
revenue, but exclude other private income and non-monetary benefits.
Table 3: Selected data from surveys of health workers in Ghana, Burkina Faso, Zambia, and Nigeria
678
www.thelancet.com Vol 371 February 23, 2008
Health Policy
staff, who would have been paid more than their local
counterparts, were excluded from the survey.
When these salaries were compared with Malawi’s GNI
per person (US$800 in 2005), the ratio was 54 for nurses
with international NGOs, and 36·5 for the nurses with
local NGOs. These ratios were higher than those recorded
for public-sector nurses in table 3.
Finally, what about the pay of health workers compared
with other professions? The 2006 World Health Report
compared the salaries of doctors and nurses with those of
engineers and teachers, respectively; however, it extracted
data from the ILO’s annual Labour Inquiry, which was
generally old, incomplete, and unreliable for countries in
sub-Saharan Africa. Reliable data with which to make such
comparisons would be useful, for example, to inform the
debate about prioritising the pay of health workers over
other professions because of the urgency of the health
crisis.
Human resource management
One of the findings from the Zambian survey was that the
pay structure was complex, and consisted of many different
types of allowance (eg, for housing, on-call duty,
recruitment, retention, and uniform up-keep); overtime
and night duty payments; and various non-monetary
benefits.11 Such a complex structure not only incurs heavy
administrative costs, but could also lead to inconsistencies,
feelings of unfairness and mistrust in the system, and
subsequent reductions in motivation.
Another issue is regular payment. The Zambian survey
reported that 15% of staff had not always received the salary
payment that was due to them; 80% had received late
payments; and 10% of staff had had to pay a so-called
expediter’s fee to obtain their salaries.11 In Ghana, 40% of
respondents had not received their allowance for additional
duty hours regularly.10 Such tardiness is likely to discourage
feelings of loyalty and commitment in employees of the
public-sector health system.
A third issue is the progression in pay over an individual’s
working career. In Burkina Faso, pay did not increase with
the length of service in the public sector.9 By contrast,
Ghanaian salaries increased by a factor of 1·7 over the
working life of a doctor, and by 3·7 for midwives.10 The
prospect of a progression in salary over time would be
expected to improve retention of staff within the public
sector, although no empirical data from sub-Saharan Africa
exists to substantiate this hypothesis.
Fiscal and macroeconomic factors
In most countries in sub-Saharan Africa, increases in
government expenditure would be needed to raise the
overall number of health workers and to improve pay, in
both absolute and relative terms. Prospects exist for
increased allocation of government budgets to health, and
increased revenue collection. Few African countries have
reached the Abuja target of allocating 15% of their public
budget to health,27 and in low-income countries, tax
www.thelancet.com Vol 371 February 23, 2008
Ministry of
Health
($US)
Driver
Addis Ababa
University
($US)
Midrange NGO ($US) US bilateral
agency ($US)
20–45
24–48
70–120
120–450
General medical practitioner,
MD, with 2 years of service
157–252
··
330–530
··
Senior medical specialist or
assistant Professor
273–420
352
Expert medical specialist or
associate Professor
354–513
400
Programme manager
568–968
Officer 450–600
Public-health professional,
PH or PhD
260
352
Health coordinator
744–1268
Associate Director
1200–1500
Professor
··
··
447
··
Assistant Officer
450–600
··
Data are from reference 14. $US calculated from an exchange rate of $1 to 8·5 Birr.
Table 4: Monthly salary differentials between health workers in Ethiopia
Government Non-governmental Private
($US)
organisation ($US) for-profit sector
($US)
Doctor
7525
9240
Clinical officer
1915
3400
17 050
··
Midwife
1900
··
2500
Nurse
1865
2295
··
Lab technician
1915
2800
6350
Lay counsellor
··
2200
8760
Data are from reference 13.
Table 5: Comparison of average annual salaries by provider type in
Zambia in 2004
revenues amount to an average of only 15% of GDP,
compared with 30–40% in high-income countries.
Government budgets could also increase as a result of
economic growth, although the prospects of this are dismal
in the poorest countries in sub-Saharan Africa. For these
countries, any increase in public-sector employment and
pay for health workers would require sustained external or
donor financing.
However, arguments against external financing include
the volatility and unreliability of foreign financing, which
could force developing countries to cope with large
recurrent costs of salaries for health workers, if donors
withdrew their aid.
The IMF and finance ministries have argued that public
spending needs to be capped, particularly in relation to
non-traded goods and services such as domestic labour
costs, to protect against inflation, currency appreciation,
and fiscal instability.29
Another argument against external financing is that
public budgets should be used to keep reserves of foreign
currency high and to make debt repayments, rather than
to spend more on the public sector. As a result, the IMF
has redirected a large proportion of the increases in
foreign aid to Africa into international currency reserves
or domestic debt payments.28 Only 27% of new donor aid
from 1999 to 2005 was actually designated to be spent on
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Health Policy
goods and services, and in some countries this was as
low as 17%.28
Studies have shown that IMF policies hinder public
spending and social investment, and that limits on wage
bills prevent needs for education and health personnel
from being met.29,30 Moreover, the macroeconomic rationale
of the IMF’s restrictions on public spending on labour is
not supported by evidence.31
Finally, some policy makers argue that government
spending should be kept low as a means to liberalise labour
markets, encourage a competitive low-wage environment,
and attract private investment. These arguments implicitly
suggest that investments in health and education are not
pro-development, and ignore the need to build and sustain
human capacity.
Discussion
We identified insufficient quality data about the salaries
and income of health workers in sub-Saharan Africa to
adequately study the association between the income of
health workers and their morale, motivation, and choices
about career and employment. The available survey data
were limited by a lack of comparability, specificity, and
detail, due to their methods and sample sizes.
Policy questions for which data are needed include: How
do countries determine the optimum balance between
wage and non-wage expenditure within the health sector?
What is the most effective response to the patterns of
health-worker movement that aggravate inequities in
health care? What package of financial and non-financial
incentives is required to improve staffing of rural health
facilities? To what extent do salaried health workers in the
public sector generate additional income by other activities,
and what is the effect on their performance within the
health system? How important are per-diem payments in
the public sector and how do they affect the availability and
performance of workers in health facilities? What is the
effect of the pay promotion structure on retention and
motivation?
Governments, WHO, ILO, research funders, and
research institutions urgently need to generate the
necessary data. They will need to invest in research, and
perhaps more importantly, in regular surveillance and
information systems. Definitions will need to be
standardised, and the private sector needs a set of incentives
and obligations to participate in data collection. Donors
can promote strengthening of the human-resource
departments of national health ministries.
Improved data on salaries and incomes must also be
complemented with better systems and more standardised
methods to estimate the cost of living and to map the
movement of health workers within and between
countries.
Efforts to adjust the skills mix and task allocations of
health workers have focused on shifting tasks from doctors
to clinical officers and nurses, and from nurses to lay
workers and community health workers. Such shifts might
680
result in some cost savings and leave more highly skilled
health workers to do more complex clinical and supervisory
tasks. However, a system of fair pay is important for
maintenance of morale and quality, and for reduction of
attrition, especially since lay and community health
workers are frequently volunteers and therefore receive
little or no pay.
To optimise the distribution and mix of health workers,
some management of the labour market is necessary.
Non-profit organisations and donor agencies need to
consider the public good and coordinate with government
on wages rather than competing for scarce health workers.
Donors, NGOs, and Ministries of Health should instead
cooperate. For example, non-government employers could
allow their staff to work part time in government health
services or teaching institutions.
The recent drafting of a Code of Conduct by international
NGOs to help ensure that their activities contribute to
building public health systems is a welcome development.32
The draft code covers six areas of NGO activity, and
explicitly recognises that NGOs can undermine the health
system by employing health workers, managers, and
leaders, and by isolating communities from formal health
systems. Quite how such a cooperative model would work
in practice is unclear, but a first step would be to reduce the
competition between actors in the health system over
labour.
Governments must take the lead to recruit and retain
skilled personnel within the public sector. The commitment
by African Heads of State, in the Abuja Declaration, to
spend at least 15% of government expenditure on health
has only been achieved by four countries. Expenditure
could also increase if countries worked to capture a higher
proportion of GDP as public revenue.
If governments committed to maximising their
contribution to health systems, then donor organisations
would have to assess how to support and finance the
recurrent costs of public-sector health workers on a
long-term basis. In Malawi, as part of the Sector Wide
Approach, some donors are helping to fund an ambitious
6-year Emergency Human Resource Programme for the
health sector, which includes an increase in government
salaries. For the Programme to be supported, sustained,
and replicated in similarly poor countries, the IMF, donors,
and ministries of finance would need to relax budget limits
and other macroeconomic policy restraints on public
expenditure.
Increased salary and income for the health workforce are
not the only solution to the health workforce crisis in
sub-Saharan Africa.33 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
www.thelancet.com Vol 371 February 23, 2008
Health Policy
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.
Contributors
DMcC, SW, and SB coordinated writing this paper. SW contributed data
from the Ghana survey, and TE from the Burkina Faso survey. SB extracted
data from the Zambian and Nigerian surveys. SB and JG did PPP
calculations. BP and BMcP contributed to historical analysis; DMcC
contributed to data on salary differentials between the public and private
sector; BB to macroeconomic and fiscal constraints; and SC to salary
differentials between health workers and other professional groups. All
authors have seen and approved the final version.
18
19
20
21
Conflict of interest statement
We declare that we have no conflict of interest.
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