Sophie Witter | Queen Margaret University, Edinburgh (original) (raw)

Sophie Witter is a health economist with a substantial reputation in her field of international health financing. She is widely sought-after as an adviser to governments and international organisations on pro-poor reforms to health financing systems. Crossing the policy/research divide, she is a well-respected academic, who has published more than 90 peer-reviewed articles in leading journals in her field, as well as numerous books, book chapters (in French as well as English), policy briefs, reports and presentations.

Sophie has worked in international health for nearly 30 years in Asia, Africa and transitional economies. She has exceptional research leadership, mixed methods research experience, analytical and writing skills, as well as extensive experience of teaching, technical advice, research uptake, and management. Her textbooks on health economics in developing and transitional economies are still used as key references for practitioners, while her writings on equity and health financing have contributed to a paradigm shift in the international debate about ‘cost-sharing’ for basic health care in low-income settings. Her specialist area is health policy, finance and systems in low and middle-income countries, including fragile and conflict-affected settings.

Sophie holds the post of Professor of International Health Financing and Health Systems at the Institute for Global Health and Development, Queen Margaret University, Edinburgh. She is also co-Research Director of the ReBUILD research consortium, which is focussing on health systems in post-conflict countries (DFID, 2011-2019). In addition, Sophie is Deputy Director of the NIHR Research Unit on Health in Fragility at Queen Margaret University, Edinburgh (2017-21); Co-Investigator of VAPAR (Using verbal autopsy with participatory action research in South Africa, 2017-22); Co-Principal Investigator of Results4TB (Designing and evaluating incentives for TB providers in Georgia, 2017-21); and Co-Investigator of the Resilience project (Understanding and modelling resilient health systems for Palestinian refugees displaced from Syria, 2016-18).

Sophie undertakes technical advisory work, independently and as an Oxford Policy Management Associate. Current and recent examples include: leading a study on UHC and equity for the OECD; acting as principal adviser to a Gates Foundation study of learning for action across health systems; leading a labour market study in Guinea for the World Bank; developing guidelines for the WHO on health financing in fragile states; and developing a transition plan for Ghana in moving away from dependent on donor support in health (funded by DFID).

In addition to research and technical advice, Sophie supervises PhD students and teaches periodically on short courses and Masters, by invitation, as well as acting as external examiner for theses.

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Papers by Sophie Witter

Background Decentralised and evidence-informed health systems rely on managers and practitioners ... more Background Decentralised and evidence-informed health systems rely on managers and practitioners at all levels having sufficient ‘decision space’ to make timely locally informed and locally relevant decisions. Our objectives were to: (a) understand decision spaces in terms of constraints and enablers (using a framework focused on authority, accountability and capacity and the interrelationships between these domains); and (b) outline opportunities through which to expand and enhance them in an understudied rural context in South Africa. Methods This study examined decision spaces within Mpumalanga Province, using data and insights generated through a participatory action research process with local communities and health system stakeholders since 2015, which was triangulated with published documents and research team participant observation to produce findings on the three core domains at three levels of the health system. Results There is significant capacity in the system, which i...

Human Resources for Health

Many high- and middle-income countries face challenges in developing and maintaining a health wor... more Many high- and middle-income countries face challenges in developing and maintaining a health workforce which can address changing population health needs. They have experimented with interventions which overlap with but have differences to those documented in low- and middle-income countries, where many of the recent literature reviews were undertaken. The aim of this paper is to fill that gap. It examines published and grey evidence on interventions to train, recruit, retain, distribute, and manage an effective health workforce, focusing on physicians, nurses, and allied health professionals in high- and middle-income countries. A search of databases, websites, and relevant references was carried out in March 2019. One hundred thirty-one reports or papers were selected for extraction, using a template which followed a health labor market structure. Many studies were cross-cutting; however, the largest number of country studies was focused on Canada, Australia, and the United State...

This Provisional PDF corresponds to the article as it appeared upon acceptance. Fully formatted P... more This Provisional PDF corresponds to the article as it appeared upon acceptance. Fully formatted PDF and full text (HTML) versions will be made available soon. Removing financial barriers to access reproductive, maternal and newborn health services: the challenges and policy implications for human resources for health

Health Systems & Reform, 2021

ABSTRACT A debate about how best to finance essential health care in low- and middle-income setti... more ABSTRACT A debate about how best to finance essential health care in low- and middle-income settings has been running for decades, with public health systems often failing to provide reliable and adequate funding for primary health care in particular. Since 2000, many have advocated and experimented with performance-based financing as one approach to addressing this problem. More recently, in light of concerns over high transaction costs, mixed results and challenges of sustainability, a less conditional approach, sometimes called direct facility financing, has come into favor. In this commentary, we examine the evidence for the effectiveness of both modalities and argue that they share many features and requirements for effectiveness. In the right context, both can contribute to health system strengthening, and they should be seen as potentially complementary, rather than as rivals.

 There is need for intensive capacity development to ensure that the human resources function is... more  There is need for intensive capacity development to ensure that the human resources function is carried out by individuals with the right competencies.  Policies should be monitored and evaluated and the findings from such processes should be made available to a wide audience rather than to a select few.

Most countries face challenges attracting and retaining health staff in remote areas but this is ... more Most countries face challenges attracting and retaining health staff in remote areas but this is especially acute in fragile and shock-prone contexts, like Guinea, where imbalances in staffing are high and financial and governance arrangements to address rural shortfalls are weak. The objective of this study was to understand how health staff could be better motivated to work and remain in rural, under-served areas in Guinea. In order to inform the policy dialogue on strengthening human resources for health, we conducted three nationally representative cross-sectional surveys, adapted from tools used in other fragile contexts. We found that the locational job preferences of health workers in Guinea are particularly influenced by opportunities for training, working conditions, and housing. Most staff are satisfied with their work and with supervision, however, financial aspects and working conditions are considered least satisfactory, and worrying findings include the high proportion...

WIDER Working Paper, 2017

This study has been prepared within the UNU-WIDER project on 'Extractives for development (E4D)',... more This study has been prepared within the UNU-WIDER project on 'Extractives for development (E4D)', which is part of a larger project on 'Macro-economic management (M-EM)'.

BMC Health Services Research, 2017

Health Policy and Planning, 2017

This article is grounded in a research programme which set out to understand how to rebuild healt... more This article is grounded in a research programme which set out to understand how to rebuild health systems post-conflict. Four countries were studied-Uganda, Sierra Leone, Zimbabwe and Cambodia-which were at different distances from conflict and crisis, as well as having unique conflict stories. During the research process, the Ebola epidemic broke out in West Africa. Zimbabwe has continued to face a profound economic crisis. Within our research on health worker incentives, we captured insights from 128 life histories and in-depth interviews with a variety of staff that had remained in service. This article aims to draw together lessons from these contexts which can provide lessons for enhancing staff and therefore health system resilience in future, especially in similarly fragile and conflict-affected contexts. We examine the reported effects, both personal and professional, of the three different types of shock (conflicts, epidemics and prolonged political-economic crises), and how staff coped. We find that the impact of shocks and coping strategies are similar between conflict/post-conflict and epidemic contexts-particularly in relation to physical threats and psychosocial threats-while all three contexts create challenges and staff responses for working conditions and remuneration. Health staff showed considerable inventiveness and resilience, and also benefited from external assistance of various kinds, but there are important gaps which point to ways in which they should be better protected and supported in the future. Health systems are increasingly fragile and conflict-prone, and shocks are often prolonged or repeated. Resilience should not be taken for granted or used as an excuse for abandoning frontline health staff. Strategies should be in place at local, national and international levels to prepare for predictable crises of various sorts, rather than waiting for them to occur and responding belatedly, or relying on personal sacrifices by staff to keep services functioning.

PloS one, 2018

Performance-based financing (PBF) schemes have been expanding rapidly across low and middle incom... more Performance-based financing (PBF) schemes have been expanding rapidly across low and middle income countries in the past decade, with considerable external financing from multilateral, bilateral and global health initiatives. Many of these countries have been fragile and conflict-affected (FCAS), but while the influence of context is acknowledged to be important to the operation of PBF, there has been little examination of how it affects adoption and implementation of PBF. This article lays out initial hypotheses about how FCAS contexts may influence the adoption, adaption, implementation and health system effects of PBF. These are then interrogated through a review of available grey and published literature (140 documents in total, covering 23 PBF schemes). We find that PBF has been more common in FCAS contexts, which were also more commonly early adopters. Very little explanation of the rationale for its adoption, in particular in relation with the contextual features, is given in...

The International journal of health planning and management, Jan 12, 2018

While there is a growing body of literature on how to attract and retain health workers once they... more While there is a growing body of literature on how to attract and retain health workers once they are trained, there is much less published on what motivates people to train as health professions in the first place in low- and middle-income countries and what difference this makes to later retention. In this article, we examine patterns in expressed motivation to join the profession across different cadres, based on 103 life history interviews conducted in northern Uganda, Sierra Leone, Cambodia, and Zimbabwe. A rich mix of reported motivations for joining the profession was revealed, including strong influence of "personal calling," exhortations of family and friends, early experiences, and chance factors. Desire for social status and high respect for health professionals were also significant. Economic factors are also important-not just perceptions of future salaries and job security but also more immediate ones, such as low cost or free training. These allowed low-inco...

The International journal of health planning and management, Jan 12, 2018

This article presents the findings of a theory-based evaluation of the Sierra Leone Free Health C... more This article presents the findings of a theory-based evaluation of the Sierra Leone Free Health Care Initiative (FHCI), using mixed methods. Analytical approaches included time-series analysis of national survey data to examine mortality and morbidity trends, as well as modelling of impact using the Lives Saved Tool and expenditure trend analysis. We find that the FHCI responded to a clear need in Sierra Leone, was well designed to bring about needed changes in the health system to deliver services to the target beneficiaries, and did indeed bring funds and momentum to produce important systemic reforms. However, its ambition was also a risk, and weaknesses in implementation have been evident in a number of core areas, such as drugs supply. We conclude that the FHCI was one important factor contributing to improvements in coverage and equity of coverage of essential services for mothers and children. Modelled cost-effectiveness is high-in the region of US$ 420 to US$ 444 per life ye...

Health research policy and systems, Jan 2, 2017

The Demand-Driven Evaluations for Decisions (3DE) programme was piloted in Zambia and Uganda in 2... more The Demand-Driven Evaluations for Decisions (3DE) programme was piloted in Zambia and Uganda in 2012-2015. It aimed to answer evaluative questions raised by policymakers in Ministries of Health, rapidly and with limited resources. The aim of our evaluation was to assess whether the 3DE model was successful in supporting and increasing evidence-based policymaking, building capacity and changing behaviour of Ministry staff. Using mixed methods, we compared the ex-ante theory of change with what had happened in practice, why and with what results (intended and unintended), including a qualitative assessment of 3DE's contribution. Data sources included a structured quality assessment of the five impact evaluations produced, 46 key informant interviews at national and international levels, structured extraction from 170 programme documents, a wider literature review of relevant topics, and a political economy analysis conducted in Zambia. We found that 3DE had a very limited contribu...

Health Policy and Planning, 2017

Studies in family planning, 2016

The article describes an international collaboration that systematically reviewed the evidence on... more The article describes an international collaboration that systematically reviewed the evidence on financing mechanisms for family planning/contraception, assessed the strength of and summarized the evidence, identified research gaps, and proposed a new research agenda to address the gaps. The review found that the evidence base is weak owing to the paucity of studies, diversity in findings, and variations in intervention, study design, and outcome measures. Of more than 17,000 papers reviewed only 38 met the eligibility criteria. A number of general recommendations on the directions and areas of future research can be drawn. There is a strong need for more robust study designs on the effectiveness of financial incentives in family planning.

BMC Health Services Research, 2016

Background: There is growing interest on the impact of performance-based financing (PBF) on healt... more Background: There is growing interest on the impact of performance-based financing (PBF) on health workers' 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.

Tropical Medicine & International Health, 2015

Human Resources for Health, 2015

Human Resources for Health, 2015

Background: Human resources for health represent an essential component of health systems and pla... more 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. Findings: 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.

Background Decentralised and evidence-informed health systems rely on managers and practitioners ... more Background Decentralised and evidence-informed health systems rely on managers and practitioners at all levels having sufficient ‘decision space’ to make timely locally informed and locally relevant decisions. Our objectives were to: (a) understand decision spaces in terms of constraints and enablers (using a framework focused on authority, accountability and capacity and the interrelationships between these domains); and (b) outline opportunities through which to expand and enhance them in an understudied rural context in South Africa. Methods This study examined decision spaces within Mpumalanga Province, using data and insights generated through a participatory action research process with local communities and health system stakeholders since 2015, which was triangulated with published documents and research team participant observation to produce findings on the three core domains at three levels of the health system. Results There is significant capacity in the system, which i...

Human Resources for Health

Many high- and middle-income countries face challenges in developing and maintaining a health wor... more Many high- and middle-income countries face challenges in developing and maintaining a health workforce which can address changing population health needs. They have experimented with interventions which overlap with but have differences to those documented in low- and middle-income countries, where many of the recent literature reviews were undertaken. The aim of this paper is to fill that gap. It examines published and grey evidence on interventions to train, recruit, retain, distribute, and manage an effective health workforce, focusing on physicians, nurses, and allied health professionals in high- and middle-income countries. A search of databases, websites, and relevant references was carried out in March 2019. One hundred thirty-one reports or papers were selected for extraction, using a template which followed a health labor market structure. Many studies were cross-cutting; however, the largest number of country studies was focused on Canada, Australia, and the United State...

This Provisional PDF corresponds to the article as it appeared upon acceptance. Fully formatted P... more This Provisional PDF corresponds to the article as it appeared upon acceptance. Fully formatted PDF and full text (HTML) versions will be made available soon. Removing financial barriers to access reproductive, maternal and newborn health services: the challenges and policy implications for human resources for health

Health Systems & Reform, 2021

ABSTRACT A debate about how best to finance essential health care in low- and middle-income setti... more ABSTRACT A debate about how best to finance essential health care in low- and middle-income settings has been running for decades, with public health systems often failing to provide reliable and adequate funding for primary health care in particular. Since 2000, many have advocated and experimented with performance-based financing as one approach to addressing this problem. More recently, in light of concerns over high transaction costs, mixed results and challenges of sustainability, a less conditional approach, sometimes called direct facility financing, has come into favor. In this commentary, we examine the evidence for the effectiveness of both modalities and argue that they share many features and requirements for effectiveness. In the right context, both can contribute to health system strengthening, and they should be seen as potentially complementary, rather than as rivals.

 There is need for intensive capacity development to ensure that the human resources function is... more  There is need for intensive capacity development to ensure that the human resources function is carried out by individuals with the right competencies.  Policies should be monitored and evaluated and the findings from such processes should be made available to a wide audience rather than to a select few.

Most countries face challenges attracting and retaining health staff in remote areas but this is ... more Most countries face challenges attracting and retaining health staff in remote areas but this is especially acute in fragile and shock-prone contexts, like Guinea, where imbalances in staffing are high and financial and governance arrangements to address rural shortfalls are weak. The objective of this study was to understand how health staff could be better motivated to work and remain in rural, under-served areas in Guinea. In order to inform the policy dialogue on strengthening human resources for health, we conducted three nationally representative cross-sectional surveys, adapted from tools used in other fragile contexts. We found that the locational job preferences of health workers in Guinea are particularly influenced by opportunities for training, working conditions, and housing. Most staff are satisfied with their work and with supervision, however, financial aspects and working conditions are considered least satisfactory, and worrying findings include the high proportion...

WIDER Working Paper, 2017

This study has been prepared within the UNU-WIDER project on 'Extractives for development (E4D)',... more This study has been prepared within the UNU-WIDER project on 'Extractives for development (E4D)', which is part of a larger project on 'Macro-economic management (M-EM)'.

BMC Health Services Research, 2017

Health Policy and Planning, 2017

This article is grounded in a research programme which set out to understand how to rebuild healt... more This article is grounded in a research programme which set out to understand how to rebuild health systems post-conflict. Four countries were studied-Uganda, Sierra Leone, Zimbabwe and Cambodia-which were at different distances from conflict and crisis, as well as having unique conflict stories. During the research process, the Ebola epidemic broke out in West Africa. Zimbabwe has continued to face a profound economic crisis. Within our research on health worker incentives, we captured insights from 128 life histories and in-depth interviews with a variety of staff that had remained in service. This article aims to draw together lessons from these contexts which can provide lessons for enhancing staff and therefore health system resilience in future, especially in similarly fragile and conflict-affected contexts. We examine the reported effects, both personal and professional, of the three different types of shock (conflicts, epidemics and prolonged political-economic crises), and how staff coped. We find that the impact of shocks and coping strategies are similar between conflict/post-conflict and epidemic contexts-particularly in relation to physical threats and psychosocial threats-while all three contexts create challenges and staff responses for working conditions and remuneration. Health staff showed considerable inventiveness and resilience, and also benefited from external assistance of various kinds, but there are important gaps which point to ways in which they should be better protected and supported in the future. Health systems are increasingly fragile and conflict-prone, and shocks are often prolonged or repeated. Resilience should not be taken for granted or used as an excuse for abandoning frontline health staff. Strategies should be in place at local, national and international levels to prepare for predictable crises of various sorts, rather than waiting for them to occur and responding belatedly, or relying on personal sacrifices by staff to keep services functioning.

PloS one, 2018

Performance-based financing (PBF) schemes have been expanding rapidly across low and middle incom... more Performance-based financing (PBF) schemes have been expanding rapidly across low and middle income countries in the past decade, with considerable external financing from multilateral, bilateral and global health initiatives. Many of these countries have been fragile and conflict-affected (FCAS), but while the influence of context is acknowledged to be important to the operation of PBF, there has been little examination of how it affects adoption and implementation of PBF. This article lays out initial hypotheses about how FCAS contexts may influence the adoption, adaption, implementation and health system effects of PBF. These are then interrogated through a review of available grey and published literature (140 documents in total, covering 23 PBF schemes). We find that PBF has been more common in FCAS contexts, which were also more commonly early adopters. Very little explanation of the rationale for its adoption, in particular in relation with the contextual features, is given in...

The International journal of health planning and management, Jan 12, 2018

While there is a growing body of literature on how to attract and retain health workers once they... more While there is a growing body of literature on how to attract and retain health workers once they are trained, there is much less published on what motivates people to train as health professions in the first place in low- and middle-income countries and what difference this makes to later retention. In this article, we examine patterns in expressed motivation to join the profession across different cadres, based on 103 life history interviews conducted in northern Uganda, Sierra Leone, Cambodia, and Zimbabwe. A rich mix of reported motivations for joining the profession was revealed, including strong influence of "personal calling," exhortations of family and friends, early experiences, and chance factors. Desire for social status and high respect for health professionals were also significant. Economic factors are also important-not just perceptions of future salaries and job security but also more immediate ones, such as low cost or free training. These allowed low-inco...

The International journal of health planning and management, Jan 12, 2018

This article presents the findings of a theory-based evaluation of the Sierra Leone Free Health C... more This article presents the findings of a theory-based evaluation of the Sierra Leone Free Health Care Initiative (FHCI), using mixed methods. Analytical approaches included time-series analysis of national survey data to examine mortality and morbidity trends, as well as modelling of impact using the Lives Saved Tool and expenditure trend analysis. We find that the FHCI responded to a clear need in Sierra Leone, was well designed to bring about needed changes in the health system to deliver services to the target beneficiaries, and did indeed bring funds and momentum to produce important systemic reforms. However, its ambition was also a risk, and weaknesses in implementation have been evident in a number of core areas, such as drugs supply. We conclude that the FHCI was one important factor contributing to improvements in coverage and equity of coverage of essential services for mothers and children. Modelled cost-effectiveness is high-in the region of US$ 420 to US$ 444 per life ye...

Health research policy and systems, Jan 2, 2017

The Demand-Driven Evaluations for Decisions (3DE) programme was piloted in Zambia and Uganda in 2... more The Demand-Driven Evaluations for Decisions (3DE) programme was piloted in Zambia and Uganda in 2012-2015. It aimed to answer evaluative questions raised by policymakers in Ministries of Health, rapidly and with limited resources. The aim of our evaluation was to assess whether the 3DE model was successful in supporting and increasing evidence-based policymaking, building capacity and changing behaviour of Ministry staff. Using mixed methods, we compared the ex-ante theory of change with what had happened in practice, why and with what results (intended and unintended), including a qualitative assessment of 3DE's contribution. Data sources included a structured quality assessment of the five impact evaluations produced, 46 key informant interviews at national and international levels, structured extraction from 170 programme documents, a wider literature review of relevant topics, and a political economy analysis conducted in Zambia. We found that 3DE had a very limited contribu...

Health Policy and Planning, 2017

Studies in family planning, 2016

The article describes an international collaboration that systematically reviewed the evidence on... more The article describes an international collaboration that systematically reviewed the evidence on financing mechanisms for family planning/contraception, assessed the strength of and summarized the evidence, identified research gaps, and proposed a new research agenda to address the gaps. The review found that the evidence base is weak owing to the paucity of studies, diversity in findings, and variations in intervention, study design, and outcome measures. Of more than 17,000 papers reviewed only 38 met the eligibility criteria. A number of general recommendations on the directions and areas of future research can be drawn. There is a strong need for more robust study designs on the effectiveness of financial incentives in family planning.

BMC Health Services Research, 2016

Background: There is growing interest on the impact of performance-based financing (PBF) on healt... more Background: There is growing interest on the impact of performance-based financing (PBF) on health workers' 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.

Tropical Medicine & International Health, 2015

Human Resources for Health, 2015

Human Resources for Health, 2015

Background: Human resources for health represent an essential component of health systems and pla... more 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. Findings: 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.