Performance-based financing in the context of the complex remuneration of health workers: findings from a mixed-method study in rural Sierra Leone
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Date
2016-07-19Author
Bertone, Maria Paola
Lagarde, M.
Witter, Sophie
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Bertone, M., Lagarde, M. & Witter, S. (2016) Performance-based financing in the context of the complex remuneration of health workers: findings from a mixed-method study in rural Sierra Leone, BMC Health Services Research, vol. 16, , ,
Abstract
motivation and performance. However, the literature so far tends to look at PBF payments in isolation, without
reference to the overall remuneration of health workers. Taking the case of Sierra Leone, where PBF was introduced
in 2011, this study investigates the absolute and relative contribution of PBF to health workers' income and explores
their views on PBF bonuses, in comparison to and interaction with other incomes.
Methods: The study is based on a mixed-methods research consisting in a survey and an 8-week longitudinal logbook
collecting data on the incomes of primary health workers (n = 266) and 39 in-depth interviews with a subsample of the
same workers, carried out in three districts of Sierra Leone (Bo, Kenema and Moyamba).
Results: Our results show that in this setting PBF contributes about 10 % of the total income of health workers.
Despite this relatively low contribution, their views on the bonuses are positive, especially compared to the negative
views on salary. We find that this is because PBF is seen as a complement, with less sense of entitlement compared to
the official salary. Moreover, PBF has a specific role within the income utilization strategies enacted by health workers,
as it provides extra money which can be used for emergencies or reinvested in income generating activities. However,
implementation issues with the PBF scheme, such as delays in payment and difficulties in access, cause a
series of problems that limit the motivational effects of the incentives. Overall, staff still favor salary increases
over increases in PBF.
Conclusions: The study confirms that the remuneration of health workers is complex and interrelated so that
the different financial incentives cannot be examined independently from one. It also shows that the implementation
of PBF schemes has an impact on the way it does or does not motivate health workers, and must be thoroughly
researched in order to assess the impact of PBF.