title: A cross-sectional study of the income sources of primary care health workers in the Democratic Republic of Congo.
abstract: In the Democratic Republic of Congo (DRC), the state system to remunerate health workers is poorly functional, encouraging diversification of income sources and corruption. Given the central role that health workers play in health systems, policy-makers need to ensure health workers are remunerated in a way which best incentivises them to provide effective and good quality services. This study describes the different sources and quantities of income paid to primary care health workers in Equateur, Maniema, Kasai Occidental, Province Orientale and Kasai Oriental provinces. It also explores characteristics associated with the receipt of different sources of income.
  
  
  
  Quantitative data on the income received by health workers were collected through baseline surveys. Descriptive statistics explored the demographic characteristics of health workers surveyed, and types and amounts of incomes received. A series of regression models were estimated to examine the health worker and facility-level determinants of receiving each income source and of levels received. Qualitative data collection was carried out in Kasai Occidental province to explore perceptions of each income source and reasons for receiving each.
  
  
  
  Nurses made up the majority of workers in primary care. Only 31% received a government salary, while 75% reported compensation from user fees. Almost half of all nurses engaged in supplemental non-clinical activities. Receipt of government payments was associated with income from private practice and non-clinical activities. Male nurses were more likely to receive per diems, performance payments, and higher total remuneration compared to females. Contextual factors such as provincial location, presence of externally financed health programmes and local user fee policy also influenced the extent to which nurses received many income sources.
  
  
  
  The receipt of government payments was unreliable and had implications for receipt of other income sources. A mixture of individual, facility and geographical factors were associated with the receipt of various income sources. Greater co-ordination is needed between partners involved in health worker remuneration to design more effective financial incentive packages, reduce the fragmentation of incomes and improve transparency in the payment of workers in the DRC.
authors.affiliation: London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom. Rishma.Maini@lshtm.ac.uk.
authors.forename: Rishma
authors.identifier: 0000-0002-0835-6154
authors.initials: R
authors.lastname: Maini
authors.affiliation: School of Public Health and Tropical Medicine, Tulane University, 1440 Canal Street, New Orleans, LA, 70112, United States of America.
authors.forename: David R
authors.initials: DR
authors.lastname: Hotchkiss
authors.affiliation: London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom.
authors.forename: Josephine
authors.initials: J
authors.lastname: Borghi
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D015023:Democratic Republic of the Congo; D003906:Developing Countries; D004651:Employment; D018588:Fee-for-Service Plans; D005260:Female; D006076:Government; D006282:Health Personnel / Q000191:economics; D006296:Health Services; D006801:Humans; D007182:Income; D008297:Male; D008875:Middle Aged; D009042:Motivation; D009726:Nurses / Q000191:economics*; D011320:Primary Health Care; D017150:Public Sector; D011787:Quality of Health Care; D012052:Reimbursement, Incentive; D060926:Remuneration; D012456:Salaries and Fringe Benefits; D063507:Sexism
keywords: DRC; Health workers; Income; Primary care; Remuneration