DIRECTIONS IN DEVELOPMENT Human Development Working in Health Financing and Managing the Public Sector Health Workforce Marko Vujicic, Kelechi Ohiri, Susan Sparkes Authors Delivered by The World Bank e-library to: World Health Organization IP : 158.232.3.98 Thu, 18 Jun 2009 12:54:36 (c) The International Bank for Reconstruction and Development / The World Bank Delivered by The World Bank e-library to: World Health Organization IP : 158.232.3.98 Thu, 18 Jun 2009 12:54:36 (c) The International Bank for Reconstruction and Development / The World Bank Working in Health Delivered by The World Bank e-library to: World Health Organization IP : 158.232.3.98 Thu, 18 Jun 2009 12:54:36 (c) The International Bank for Reconstruction and Development / The World Bank Delivered by The World Bank e-library to: World Health Organization IP : 158.232.3.98 Thu, 18 Jun 2009 12:54:36 (c) The International Bank for Reconstruction and Development / The World Bank Working in Health Financing and Managing the Public Sector Health Workforce Marko Vujicic Kelechi Ohiri Susan Sparkes With contributions from Aly Sy Tim Martineau Christoph Kurowski Claudia Rozas Andrew Mitchell Kyla Hayford and Sherry Madan Delivered by The World Bank e-library to: World Health Organization IP : 158.232.3.98 Thu, 18 Jun 2009 12:54:36 (c) The International Bank for Reconstruction and Development / The World Bank © 2009 The International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org E-mail: [email protected] All rights reserved 1 2 3 4 11 10 09 This volume is a product of the staff of the International Bank for Reconstruction and Development / The World Bank. 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Public health personnel—Salaries, etc.—Developing countries. 2. Medical economics—Developing countries. I. Ohiri, Kelechi. II. Sparkes, Susan. III. World Bank. IV. Title. V. Series: Directions in develop- ment (Washington, D.C.) [DNLM: 1. Health Manpower—economics—Dominican Republic. 2. Health Manpower—economics— Kenya. 3. Health Manpower—economics—Rwanda. 4. Health Manpower—economics—Zambia. 5. Health Manpower—organization & administration—Dominican Republic. 6. Health Manpower— organization & administration—Kenya. 7. Health Manpower—organization & administration—Rwanda. 8. Health Manpower—organization & administration—Zambia. 9. Developing Countries—Dominican Republic. 10. Developing Countries—Kenya. 11. Developing Countries—Rwanda. 12. Developing Countries—Zambia. 13. Salaries and Fringe Benefits—legislation & jurisprudence—Dominican Republic. 14. Salaries and Fringe Benefits—legislation & jurisprudence—Kenya. 15. Salaries and Fringe Benefits— legislation & jurisprudence—Rwanda. 16. Salaries and Fringe Benefits—legislation & jurisprudence— Zambia. W 76 V989w 2009]Delivered by The World Bank e-library to: World Health Organization RA410.55.D48V85 2009 IP : 158.232.3.98 362.1—dc22 Thu, 18 Jun 2009 12:54:36 2008051555 Cover image: Photo Courtesy of the Bill & Melinda Gates Foundation Cover design: Quantum Think (c) The International Bank for Reconstruction and Development / The World Bank Contents Foreword xv Acknowledgments xix Executive Summary xxi Abbreviations xxvii Chapter 1 Overview1 The Wage Bill Budgeting Process in the Public Sector7 The Effect of the Wage Bill Budgeting Process on the Health Workforce 21 Managing Health Wage Bill Resources in the Public Sector 24 Policy Options to Address Fiscal Constraints on the Health Wage Bill and to Improve Management of the Health Workforce in the Public Sector 37 Notes 55 ReferencesDelivered by The World Bank e-library to: 55 World Health Organization IP : 158.232.3.98 Chapter 2 BackgroundThu, Country 18 Jun 2009 Study 12:54:36 for Kenya 61 The Health Wage Bill in Kenya 62 Public Sector Employment of Health Workers 74 v (c) The International Bank for Reconstruction and Development / The World Bank vi Contents Key Messages 87 Notes 90 References 91 Chapter 3 Background Country Study for Zambia 93 The Health Wage Bill in Zambia 94 Public Sector Employment of Health Workers 108 Key Messages 121 Notes 123 References 125 Chapter 4 Background Country Study for Rwanda 127 The Health Wage Bill in Rwanda 127 Public Sector Employment of Health Workers 139 Donor Funding of Health and Education Workers’ Salaries 148 Key Messages 150 Annex 152 Notes 162 References 162 Chapter 5 Background Country Study for the Dominican Republic 165 The Health Wage Bill in the Dominican Republic 166 Public Sector Employment of Health Workers 182 Key Messages 194 Notes 197 References 197 Appendix A Comparative Analysis of Health Outcomes, Service Delivery, and Health Workforce Levels in Kenya, Zambia, Rwanda, and the Dominican Republic 199 Delivered by The World Bank e-library to: World Health Organization Appendix B Analysis of theIP Share : 158.232.3.98 of Government Health ExpenditureThu, Going 18 Jun to2009 the 12:54:36 Health Wage Bill: Some Stylized Facts 207 (c) The International Bank for Reconstruction and Development / The World Bank Contents vii Appendix C Decentralization and Human Resources for Health 215 Appendix D Review of Alternative Compensation Methods for Health Workers 233 Appendix E Review of GFATM Round 6 and GAVI HSS Round 1 Policies and Practices for Funding Health Worker Remuneration 253 Index 265 Boxes Chapter 1 Overview1 1.1 Challenges of Civil Service and Administrative Reform 39 1.2 The Kenya Emergency Hiring Program: A Promising Practice in Using Donor Assistance to Scale Up the Health Workforce 45 1.3 Summary of Policies and Practices in GFATM and GAVI HSS for Remuneration of Health Workers 46 1.4 Political Economy of Removing Health Workers from the Civil Service 53 Chapter 3 Background Country Study for Zambia 93 3.1 Confirming That an Existing Post Has Become Vacant 113 Appendix C Decentralization and Human Resources for Health 215 C.1 A Tale of Two Ugandas: Successes and Failures in Administrative Efficiency under Decentralized Human Resource Management 222 Appendix D Review of Alternative Compensation Methods for Health Workers 233 D.1 Provider Payment Mechanisms and Performance: How Fee-for-Service,Delivered Capitation, by The World and Bank Salaried e-library Systems to: Affect World Health Organization Health Worker PerformanceIP : 158.232.3.98 238 D.2 Case Study: PerformanceThu, 18 Jun Contracts 2009 12:54:36 with Physicians in Romania 242 (c) The International Bank for Reconstruction and Development / The World Bank viii Contents D.3 Case Study: Contracting In and Contracting Out in Cambodia 243 Appendix E Review of GFATM Round 6 and GAVI HSS Round 1 Policies and Practices for Funding Health Worker Remuneration 253 E.1 Examples of Countries Using GFATM Grants to Pay Health Workers 260 Figures Chapter 1 Overview1 1.1 Focus of Report4 1.2 Performance on Selected Health, Service Delivery, and Staffing Outcomes Relative to Income and Health Spending in the Dominican Republic, Kenya, Rwanda, and Zambia, 20056 1.3 Public Sector Wage Bill as a Share of GDP, 2000–08 10 1.4 A Comparison of the Health Wage Bill Budgeting Process 12 1.5 Health Wage Bill as a Share of Overall Wage Bill, 2000–07 14 1.6 Change in Public Sector Health Wage Bill versus Change in Total Public Sector Wage Bill: Sample Countries over Selected Years 15 1.7 Distribution of Civil Service Employees by Sector, 1996–2000 19 Chapter 2 Background Country Study for Kenya 61 2.1 Public Sector Wage Bill as a Share of GDP, by Region, 2005 64 2.2 Public Sector Wage Bill as a Share of Government Expenditure by Region, 2005 65 2.3 Public Sector Wage Bill as a Share of GDP, 2000–06 66 2.4 Public Sector Wage Bill as a Share of Government Expenditure, 2000–07 67 2.5 Health ExpenditureDelivered