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Table 3 Comparing results with predicted changes, health worker incentives survey, Ghana

From: Working practices and incomes of health workers: evidence from an evaluation of a delivery fee exemption scheme in Ghana

Indicators Results Comments
1. Salary and allowances Change in real terms of basic income (salary plus ADHA) over two years of:
30% for doctors and MAs; 37% for public midwives; 35% for private midwives; 28% for nurses; and 52% for community health nurses. TBAs seen drop in real income of 4% for trained and 16% for untrained.
General pay has risen for health workers. However, the fact that private midwifes have also increased their pay, while TBAs have seen a real decline, does suggest that the DFEP is affecting their incomes (positive for those groups included and negatively for the excluded groups).
2. Private practice Private practice income was almost non-existent (only 1% – two doctors – reported any). Given how small these elements are, no impact can be expected from the DFEP.
3. DFEP incentive payments Exemption incentives were reported to have been received by only 11.6% of health workers. The public midwives reported the highest average payment of ¢245,000 per month. This incentive was mainly reported by respondents from the Central Region who constituted 93.5% of the recipients. These incentives were not mandated nationally and therefore only affect regions which have decided to institute them. The figures for CR suggest that at nearly 19% of their basic salary, these incentives should have had a motivating effect on midwives.
4. Sales to patients Virtually no reports of additional income for health workers – only 3 midwives reported any. Not much change reported either (one had increase slightly; others no change). Very few responses, therefore no impact noted either way. However, there may be under-reporting (usual for informal payments etc.).
5. Working hours and client numbers All groups record increase in working hours (21% for doctors; 22% for MAs; 27.5% for public midwives; 12% for nurses; 14% for CHNs), with exception of private midwives (who report a decrease of 5%) and TBAs (who report a decrease of 9% for trained and no change for untrained) As population growth is in the region of 2.6% per annum, these large increases for public sector workers cannot simply be attributed to that. They suggest that the DFEP is increasing their workload. The picture is more complex for private midwives, who report and increase in clients and income, but a decrease in working hours and no change in deliveries. It may be that they are switching to other services or being paid more for the stable number of deliveries that they are performing. For TBAs the picture is clear: decline in income, working hours, clients and deliveries, which are likely to be attributable, at least in part, to the DFEP.
  All groups record increase in clients per week (7% for doctors; 11% for MAs; 17% for midwives; 36% for private midwives; 9% for nurses; 14% for CHNs), with exception of TBAs (who report a decrease of 11% for trained and 14% for untrained TBAs)  
  All groups record increase in deliveries per week (27% for doctors; 33% for MAs; 36% for midwives; 27% for nurses and 11% for CHNs), with exception of private midwives (no change) and TBAs (decrease of a third for both types).  
6. Working conditions 76% of respondents in CR and 59% in VR felt that drugs and supplies were adequate to deal with the increases in numbers. However, only 29% in CR and 19% in VR felt that staffing was adequate. We do not know how satisfied staff were with supplies, staff numbers etc. before the policy – these factors were already constrained. However, it is clear that adequate staffing is their main concern in relation to the DFEP.
7. Psychological benefits to staff Asked about the impact of the policy on them personally, 61% report an increase in workload; 61% report an increase in income; 42% report no change in job satisfaction; and the responses to overall change in work situation is fairly equally divided between improve, worsen and no change. These responses reflect the changes reported above – more work, higher incomes and an overall neutral effect on general satisfaction.
8. TBAs' and private midwives' views TBAs and private midwives were the only groups to report a decrease in their workload due to the DFEP. They and the mission sector report a decrease in income too, in open questions. This correlates with findings above – negative impact on TBAs and ambivalent on private midwives.