title: The complex remuneration of human resources for health in low-income settings: policy implications and a research agenda for designing effective financial incentives.
abstract: BACKGROUND
  Human resources for health represent an essential component of health systems and play a key role to accelerate progress towards universal health coverage. Many countries in sub-Saharan Africa face challenges regarding the availability, distribution and performance of health workers, which could be in part addressed by providing effective financial incentives.
  
  
  METHODS
  Based on an overview of the existing literature, the paper highlights the gaps in the existing research in low-income countries exploring the different components of health workers' incomes. It then proposes a novel approach to the analysis of financial incentives and delineates a research agenda, which could contribute to shed light on this topic.
  
  
  RESULTS
  The article finds that, while there is ample research that investigates separately each of the incomes health workers may earn (for example, salary, fee-for-service payments, informal incomes, "top-ups" and per diems, dual practice and non-health activities), there is a dearth of studies which look at the health workers' "complex remuneration", that is, the whole of the financial incentives available. Little research exists which analyses simultaneously all revenues of health workers, quantifies the overall remuneration and explores its complexity, its multiple components and their features, as well as the possible interaction between income components. However, such a comprehensive approach is essential to fully comprehend health workers' incentives, by investigating the causes (at individual and system level) of the fragmentation in the income structure and the variability in income levels, as well as the consequences of the "complex remuneration" on motivation and performance. This proposition has important policy implications in terms of devising effective incentive packages as it calls for an active consideration of the role that "complex remuneration" plays in determining recruitment, retention and motivation patterns, as well as, more broadly, the performance of health systems.
  
  
  CONCLUSIONS
  This paper argues that research focusing on the health workers' "complex remuneration" is critical to address some of the most challenging issues affecting human resources for health. An empirical research agenda is proposed to fill the gap in our understanding.
authors.affiliation: ReBUILD consortium, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK. maria.bertone@lshtm.ac.uk.|ReBUILD Consortium, IIHD, Queen Margaret University, Edinburgh, UK. maria.bertone@lshtm.ac.uk.
authors.forename: Maria Paola
authors.initials: MP
authors.lastname: Bertone
authors.affiliation: ReBUILD Consortium, IIHD, Queen Margaret University, Edinburgh, UK. switter@qmu.ac.uk.
authors.forename: Sophie
authors.initials: S
authors.lastname: Witter
mesh_terms: D017954:Africa South of the Sahara; D003906:Developing Countries; D006282:Health Personnel / Q000191:economics*; D006302:Health Services Research / Q000458:organization & administration*; D006801:Humans; D009042:Motivation; D057766:Policy; D012456:Salaries and Fringe Benefits