Assessing health workers’ revenues and coping strategies in Nigeria — a mixed-methods study

Abstract

BackgroundThe setting of realistic performance-based financing rewards necessitates not just knowledge of health workers’ salaries, but of the revenue that accrues from their additional income-generating activities. This study examined the coping mechanisms of health workers in the public health sector of Nasarawa and Ondo states in Nigeria to supplement their salaries and benefits; it also estimated the proportionate value of the revenues from those coping mechanisms in relation to the health workers’ official incomes.MethodsThis study adopted a mixed-methods approach, consisting of semi-structured interviews, a review of policy documents, a survey using self-administered questionnaires, and the randomized response technique (RRT). In all, 170 health workers (86 in Ondo, 84 in Nasarawa) participated in the survey. In-depth interviews were conducted with 24 health workers (12 per state) and nine policy makers from both states.ResultsThe health workers perceived their salaries as inadequate, though most policy makers differed in this assessment. There appeared to be a considerable expenditure–income disparity among the respondents. Approximately 56% (n = 93) of the study population reported having additional earning arrangements: most reported non-medical activities such as farming and trading, but private practice was also frequently reported.Half of the respondents with additional earning arrangements stated that their income from those activities was the equivalent of half or more of their monthly salaries. Specifically, 35% (n = 32) said that they earned about half of their official monthly salaries and 15% (n = 14) reported earning the same or more than their monthly salaries from these activities. Other coping mechanisms used by the health workers included prioritizing activities that enabled the earning of per diems, collecting informal payments and gifts from patients, and pilfering drugs from facilities.ConclusionsPredatory and non-predatory mechanisms accounted for the health workers’ additional income. It may be difficult for the health workers to meet their expenses with their salaries and financial incentives; this highlights the need for the regulation of additional earnings and to implement targeted accountability mechanisms. This study indicates the value of using mixed methods when investigating sensitive issues. Future studies of this type should employ mixed methods for triangulation purposes to provide better insight into health workers’ responses.

Primary health care workers' views of motivating factors at individual, community and organizational levels: a qualitative study from Nasarawa and Ondo states, Nigeria

“…Among factors in the work environment, health workers' responses also largely corroborated with those from other LMICs. While many mentioned inadequate salaries and lack of allowances (Agyepong et al, 2004;Akwataghibe et al, 2013;Chandler et al, 2009;Joint Learning Initiative, 2004;Lakra et al, 2012;Malik et al, 2010;Willis-Shattuck et al, 2008), the most recurring grievance among them was the shortage of drugs making them incapable of providing proper treatment to their patients. In addition, supervision, particularly one that involved coaching, providing feedback on performance and boosting confidence went a long way in motivating them (Dieleman et al, 2003;Dieleman et al, 2009;Dieleman et al, 2006).…”

“…Among organizational factors, some argue that salary is one of, if not, the most important pre-requisite for motivating health workers (Agyepong et al, 2004;Chandler et al, 2009). In most LMICs, low salaries are considered to be a major source of grievance among health workers and are associated with high attrition (Agyepong et al, 2004;Akwataghibe et al, 2013;Willis-Shattuck et al, 2008). Nonetheless, extrinsic incentives for motivation do not always have to be financial in nature.…”

Analyzing the Determinants of Health Worker Performance

“…For instance, in Zambia, McCoy et al (2008) report that the wage ratio between the most qualified and the least qualified health workers fell from 19 to 1 in 1970 to 7 to 1 in 1983. A similar wage compression ratio (between 7 to 1 and 6 to 1) is found in a 2011 study in Nigeria (Akwataghibe et al 2013). This wage compression phenomenon is explained by the policies triggered by the so-called structural adjustments-the various budget austerity policies implemented by LIC governments in the 1980s and supported by the International Monetary Fund and the World Bank.…”

“…Azfar and Murrell (2009) use statistically unlikely answer patterns to estimate that at least 35 percent of respondents to a corruption survey do not respond honestly, even when using RRT. Similarly, Akwataghibe et al (2013) argue that the responses of 58 percent of health workers in their survey were unlikely to have responded candidly.…”

“…These individuals can then be excluded when analyzing responses to questions posed in the direct survey. Akwataghibe et al (2013) provide an example of this in the context of two Nigerian states.…”