title: Investigating the remuneration of health workers in the DR Congo: implications for the health workforce and the health system in a fragile setting.
abstract: The financial remuneration of health workers (HWs) is a key concern to address human resources for health challenges. In low-income settings, the exploration of the sources of income available to HWs, their determinants and the livelihoods strategies that those remunerations entail are essential to gain a better understanding of the motivation of the workers and the effects on their performance and on service provision. This is even more relevant in a setting such as the DR Congo, characterized by the inability of the state to provide public services via a well-supported and financed public workforce. Based on a quantitative survey of 1771 HWs in four provinces of the DR Congo, this article looks at the level and the relative importance of each revenue. It finds that Congolese HWs earn their living from a variety of sources and enact different strategies for their financial survival. The main income is represented by the share of user fees for those employed in facilities, and per diems and top-ups from external agencies for those in Health Zone Management Teams (in both cases, with the exception of doctors), while governmental allowances are less relevant. The determinants at individual and facility level of the total income are also modelled, revealing that the distribution of most revenues systematically favours those working in already favourable conditions (urban facilities, administrative positions and positions of authority within facilities). This may impact negatively on the motivation and performance of HWs and on their distribution patters. Finally, our analysis highlights that, as health financing and health workforce reforms modify the livelihood opportunities of HWs, their design and implementation go beyond technical aspects and are unavoidably political. A better consideration of these issues is necessary to propose contextually grounded and politically savvy approaches to reform in the DR Congo.
authors.affiliation: 15-17 Tavistock Place, London, WC1H 9SH, UK, mariapaola.bertone@gmail.com.
authors.forename: Maria Paola
authors.initials: MP
authors.lastname: Bertone
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Avenue, Seattle, WA 98121, USA and.
authors.forename: Grégoire
authors.initials: G
authors.lastname: Lurton
authors.affiliation: Ecole De Santé Publique, Université De Kinshasa, Kinshasa, BP 11850 Kin I, DR Congo.
authors.forename: Paulin Beya
authors.initials: PB
authors.lastname: Mutombo
mesh_terms: D003695:Delivery of Health Care / Q000191:economics*; D015023:Democratic Republic of the Congo; D003906:Developing Countries; D005251:Fees, Medical / Q000706:statistics & numerical data; D005381:Financing, Organized / Q000191:economics*; D006282:Health Personnel / Q000191:economics*; D006280:Health Workforce / Q000191:economics*; D061889:Healthcare Financing; D006801:Humans; D009042:Motivation; D060926:Remuneration
keywords: Democratic Republic of the Congo; financial incentives; health worker motivation; human resources for health; livelihood strategies; remuneration; user fees