GRAMÁTICA pág. 94
PRONUNCIACIÓN Y ORTOGRAFÍA ➜ Acentuación
The assessment of VfM includes summative measures, which is why we have placed it at the end of this report. This section analyses the VfM of the FHCI by assessing the economy, efficiency and cost-effectiveness of the initiative. Our final section provides additional analysis in relation to equity, which build on the equity analyses of changing outputs and outcomes in sections 5 and 6.
10.1 Economy
Economy is taken to mean the extent to which inputs have been purchased at appropriate prices, and this is generally assessed by benchmarking costs against reasonable comparators. This section focuses assessment on the economy of two key inputs to the FHCI – HR and
pharmaceuticals.
Assessing the economy of HR is generally a complicated task. Job descriptions are not uniform, some cadres of the workforce are not internationally tradable, and it can be hard to compare the relative value of salaries in different countries on an annual basis. However, there is a growing body of research into HRH, with a significant component focusing on West Africa, and Sierra Leone specifically, including through the ReBUILD research. This research has explored the remuneration of health workers in a number of countries, and is used in this analysis. The relative cost of the public sector’s HRH, as well as its HR for other key sectors such as the military, the police and education, is also presented.
Assessing the economy of drugs is simpler. Drugs are standard across the world, and are internationally tradable. This report uses the International Drug Price Indicator Guide, which has been published by Management Sciences for Health (MSH) annually since 1986 and in
collaboration with WHO since 2000. It documents a range of prices from non-profit drug suppliers and commercial procurement agencies, using current catalogues and price lists (MSH, 2015). This report attempts to compare the unit costs of drugs procured for the FHCI with the low, median and high costs documented for the same drugs in the International Drug Price Indicator Guide.
10.1.1 HRH
In a recent attempt to compare health sector staff remuneration across five countries (Ghana, Nepal, Sierra Leone, Zambia and Zimbabwe), researchers identified a series of methodological challenges (McPake et al., 2013). First, health professionals are not always defined in consistent ways. For example, it can be hard to distinguish between junior specialists, general doctors in primary care and specialists working in tertiary institutions. Sometimes enrolled and registered nurses are considered separate categories, and sometimes not. Sometimes midwives are
considered their own category, and sometimes not. Some categories of staff perform certain roles in some countries, but would not be considered qualified for the same tasks in other countries. Two key considerations for international comparisons of health worker remuneration from Sierra
Leone’s perspective are that enrolled and registered nurses are considered separate categories, and that MCH aides do not meet WHO’s definition of a SBA but are nevertheless expected to fulfil this role.
Second, ideally the value of salaries would be assessed relative to other salaries within their economies. However, good-quality data on income distributions are rare (including in Sierra Leone), so it is hard to get a sense of how health worker salaries fare relative to other salaries in the economy. McPake et al. (2013) attempt to negotiate this by expressing the salaries in relation to national income or national product per capita, but this does not capture anything to do with
inequality. This report faces the same problem and expresses salaries in terms of a national poverty line and GDP per capita, but is not able to comment on the income decile health workers fall into.
This report thus proceeds by presenting the salaries of staff working in reproductive health and family planning in Sierra Leone by cadre and compares them to national income per capita and a national poverty line. It then looks at the total cost of the public sector’s health workers as a
proportion of general government health expenditure and general government expenditure, as well as in relation to the total cost of other categories of public sector worker. Finally, it highlights that total remuneration of a health worker includes income from many streams (not just payroll), and compares estimates of this higher total remuneration across countries. Where possible, changes in these indicators are assessed, although the data do not always permit this.
Further issues that have been highlighted in the HRH section (Section 4.3) and which are relevant to the economy and efficiency of HRH include changes to absenteeism, attrition and the difference between distribution and need for health workers (Witter et al., 2015).
10.1.1.1 Health worker salaries
In 2013, the salary for an obstetrician was SLL 19,958,400 per month, which is 68 times larger than the country’s average income (measured as GDP per capita). Primary care doctors/DMOs and specialist doctors (public health) received closer to SLL 15million, or 52 times the average, and generalist/medical officers and public health sisters received close to SLL 5 million, which is 18 times the average. However, 78% of health workers providing reproductive or contraceptive services were either state enrolled community health nurses or MCH aides. They received between SLL 700,000 and 800,000 per month, between 2.4 and 2.8 times the average income (see Figure 74 below).
Figure 73: Health worker salaries in 2013, Sierra Leone
Sources: MoHS, GoSL for health worker salaries. IMF World Economic Outlook, October 2015 for GDP - 5,000,000 10,000,000 15,000,000 20,000,000 25,000,000
Sierra Leone’s Poverty Profile uses the 2003/04 and 2011 SLIHSs to measure consumption expenditure. They estimate that households with an adult equivalent consumption below SLL 1,625,568 per year in 2011 fell below the poverty line (SSL, 2013). This is equivalent to SLL 135,464 consumption per month. All relevant health workers earned between five and 150 times this.
Based on these comparisons then, health workers are a relatively well-paid segment of the Sierra Leonean economy, earning well above average national income levels. Those that are particularly well paid (Obstetricians, DMOs and public health specialists) are clearly in a social elite, earning extremely large amounts of money. A similar analysis of health worker salaries in Ghana in 2005 estimated that doctors earned 38.5 times the GNI per capita after supplementary sources of income were accounted for. It also found that a nurse received 12.09 times the GNI per capita (Witter et al., 2007). A direct comparison between Ghana in 2005 and Sierra Leone in 2013 shows that the relative wages in comparison to average national income were more spread out in Sierra Leone, with doctors receiving much more and nurses receiving much less in Sierra Leone than Ghana.
It is also worth noting, however, that while extremely high within the context of Sierra Leone, the salary of an obstetrician was just below £3,000 per month, or £36,000 per year. A Gap Medics blog in 2013 reported that the average annual salary for an obstetrician or gynaecologist in the UK was £90,000.99 The UK’s National Health Service currently advertises that the basic salary of a
specialist doctor is between £37,000 and £70,000.100 The scarcity of specialist doctors willing to
work in Sierra Leone in combination with the financial opportunities doctors have throughout the world mean that relatively high salaries may be a necessity for keeping them in the country.
10.1.1.2 Government total health sector wage bill
In 2013, 60% of GGEH was spent on health worker remuneration – up from 35% in 2008. This also meant a growth from 5–10% of total government expenditure on wages and salaries, from 2–4% of general government expenditure (GGE) and from 0.2–0.5% of GDP (see Table 41). The health workforce is now the government’s second most expensive sector workforce (see Table 41). Since 2002 the health sector has been in the top four spenders on government employees. With the introduction of the FHCI, and the pay reforms this came with, the health sector jumped over the military and the police. Only the public education sector workforce, which includes all the country’s teachers, is more expensive.
In relation to this report’s estimates of the total cost of the FHCI (including non-government sourced funds), however, the wage bill shrunk from 20.0 to 18.9% of the total cost of the FHCI between 2010 and 2013.101
99 See www.gapmedics.co.uk/blog/2013/12/30/obstetrics-and-gynaecology-career-guide-training-job-description-career-prospects/ 100 See www.healthcareers.nhs.uk/about/careers-medicine/pay-doctors
Table 41: MoHS payroll in the wider context
2008 2009 2010 2011 2012 2013
MoHS personnel as % of GGEH 35% 26% 49% 46% 51% 60%
MoHS personnel as % of GGE 2% 2% 3% 3% 3% 4%
MoHS personnel as % of total wages and salaries 5% 5% 12% 11% 10% 10% MoHS personnel as % of GDP 0.2% 0.2% 0.6% 0.6% 0.5% 0.5% MoHS personnel as % of FHCI expenditure 20.0% 19.3% 19.7% 18.9%
Source: Authors’ calculations from MoFED, GoSL documents
Figure 74: Public sector payrolls, 2002–2013 actuals
Source: MoFED, GoSL documents
10.1.1.3 Other income streams
Toward the end of 2012 researchers interviewed 312 health sector staff from the Western Area, Kenema, Bonthe and Koinadugu districts (12% of the total workforce in those areas). The idea was to get a sense of the working patterns, sources of remuneration and motivational factors for Sierra Leonean health workers (Witter et al., 2015). The study included questions on workload, working hours and different streams of income.
An important finding was that health workers receive significant income in addition to their salaries. Figure 76 below shows average self-reported breakdowns of total income, disaggregated by type of health worker. Other than pharmacists, pharmacy technicians and doctors, all professions have their salaries topped up by at least 25% through non-salary sources of income. The amounts reported here are still related to the FHCI. All professions receive significant income through daily subsistence allowances and many also get income through PBF and rural allowances. The researchers also asked about incomes from non-FHCI-related activities (e.g. private practice and non-health sector activities), which are in addition to figures presented here. The importance of this is that basic health worker salaries (as discussed above) are an underestimate of the actual cost of health workers. - 50,000 100,000 150,000 200,000 250,000 300,000 350,000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
304 Ministry of Health and Sanitation 201 Ministry of Defence
206 Police
301 Ministry of Education, Science & Technology - Including Teachers (only teachers in 2013)
This finding has also been observed elsewhere. The above-mentioned 2005 survey of health workers in Ghana found that doctors received only 34% of their income from their basic salary, with the remainder coming from allowances/benefits and a small amount from user fees and private practice (Witter et al., 2007). A similar survey to that carried out in Sierra Leone was conducted in Mali, Benin, Burkina Faso and Morocco in 2012 (Witter et al., Forthcoming). Basic salaries accounted for less than 50% of total income for doctors, midwives and nurses in Burkina Faso, between 40% and 60% in Mali, between 55% and 75% in Benin and between 65% and 90% in Morocco.102 The remainder came from sources such as government allowances, daily
subsistence allowances, bonuses and private practice activities.
A more general attempt to investigate the pay structures of public sector health workers in sub- Saharan Africa found an overall lack of quality data about salaries and incomes. However, where data did exist, they revealed significant variation across countries, with a generally high level of complexity (i.e. health workers generally receive multiple streams of income) (McCoy et al., 2008). The authors suggest such complex pay structures are administratively expensive and generate inconsistencies, feelings of unfairness and mistrust in the system, in turn dampening motivation.
Figure 75: Breakdown of health worker total incomes by source (%)
Source: Witter et al. (2015)
Once all sources of income are taken into account, it is possible to benchmark the total cost of health workers in different countries. According to self-reported total incomes and hours worked, Sierra Leonean midwives and nurses received US$ 1.58 per hour at 2012 rates. This was lower than Morocco (US$ 3.30 to US$ 3.46), higher than Benin (US$ 1.11 to US$ 1.31) and Mali (US$ 1.35 to US$ 1.51) and between the rates for midwives (US$ 2.1) and nurses (US$ 1.08) in Burkina Faso. Doctors in Sierra Leone received US$ 4.76 per hour. This was very competitive – closely in between Morocco (US$ 5.03) and Benin (US$ 4.39) and far higher than Mali (US$ 1.23) and Burkina Faso (US$ 2.60) (see Figure 77) (Witter et al., Forthcoming).
Overall then, Sierra Leonean doctors are extremely well paid and the other health cadres receive a good salary. It is important, however, to provide the circumstances in which doctors will want to work in Sierra Leone. This will be a difficult trade-off moving forward.
102 Note that allowances and salaries were not disaggregated in Morocco in Witter et al. (Forthcoming).
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Doctor CHO/CHA RN SECHN EHO MCH aide EDCU assist Lab Tech Pharmacist/PhTech