Sources, determinants and utilization of health workers’ revenues: evidence from Sierra Leone

Exploring the entire set of formal and informal payments available to health workers (HWs) is critical to understand the financial incentives they face and devise effective incentive packages to motivate them. We investigate this issue in the context of Sierra Leone by collecting quantitative data through a survey and daily logbooks on the incomes of 266 HWs in three districts, and carrying out 39 qualitative in-depth interviews. We find that, while earnings related to the HWs official jobs represent the largest share, their income is fragmented and composed of a variety of payments, and there is a large heterogeneity in the importance of each income source within the total remuneration. Importantly, each income has different features in terms of regularity, reliability, ease of access, etc. Our analysis also reveals the determinants of the incomes received and their level based on individual and facility characteristics, and finds that these are not in line with HRH policies defined at national level. Additionally, from their narratives, it emerges that HWs are 'managing', in the sense both of 'getting by' and of enacting financial coping strategies, such as mental accounting (spending different incomes differently), income hiding to shelter it from family pressures, and re-investment of incomes to stabilize overall earnings over time, in order to ensure their livelihoods and those of their families. These strategies question the assumption of fungibility of incomes and the neutrality of increasing or regulating one rather than another of them. Together, our findings on earning and income use patterns have important policy implications for how we go about (re)thinking financial incentive strategies.