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Table 1 Main hypotheses of the proposed research agenda on HRH complex remuneration and possible research questions

From: The complex remuneration of human resources for health in low-income settings: policy implications and a research agenda for designing effective financial incentives

Main issues/hypotheses Possible research questions
Complexity/fragmentation of income sources • What are the different incomes available for health workers and the level and relative importance of each income?
• To which type of health workers is each source of income available – including health worker characteristics at the individual level (such as age, gender, level of education, years in the health sector and role within the facility) and at the facility level (type of facility, rural/urban, size, location within the country, etc.)?
• What are the individual- and facility-level determinants that define the level (amount) of each income received/earned?
• How do the different incomes interact with each other? Are certain incomes used as a substitute for the lack/low level of others or rather as complements?
• How are the different incomes used by health workers?
Consequences of the complex remuneration • What are the features of the different revenues (for example, present vs. deferred and stable vs. irregular, performance-based vs. fixed), and how do these affect motivation and performance?
• How do health workers perceive their incomes, in terms of fairness, of being sufficient to motivate them, of transparency on what influences them, etc.? How do these perceptions affect their motivation and performance?
• What are the consequences of the income fragmentation on the motivation and performance? (for example, does the accumulation of payments lead to “blurriness” and decrease effectiveness of incentives?)
• How do different incomes and their fragmentation affect the time spent on different activities, levels of absenteeism and accountability links to different payers?
Differences in total income across health workers of the same cadre • What is the measure of differences of income across similar health workers? (that is, same cadre/level of education and type of post and role within facility)
• What are the drivers at the individual and facility level of these differences?
• What are the consequences of the inequalities of total income? Are they justifiable and have a motivating effect (for example, incentivizing rural workers)? Or do they cause unacceptable inequalities and hamper availability, retention and distribution, as well as motivation (for example, urban workers or workers in some areas have more opportunities to earn some revenues from private practice or donors’ support)?
Differences within countries • Are there income differences (both overall and for each component) between health workers in different areas of the same country?
• What are the causes of these differences? (for example, rural/urban divide, different socio-economic contexts, historical legacies, political economy dynamics at local level and presence of external actors)
Differences across countries • Do health workers in some countries have more complex incomes than in others? Why? (for example, different health system architecture and health system fragmentation, role of private sector, existence of free health care policies, level of health funding and fragile/post-conflict settings)
• Are individual differences for similar health workers more important in some countries than others? Why?
Designing financial incentive packages • Which tools and methods are needed to produce context-specific evidence in order to design rational and effective incentive packages for health workers?
• What is the role of governments and their development partners in reducing inequalities and fragmentation of health workers’ income?
• What are the policy implications of complex remuneration (for example, its effects on policy options and effectiveness), and what are the options for addressing it?
• How are individual-level strategies for the motivation of health workers affected and constrained by macrolevel conditions (for example, wage bills caps)?