Can financial retention incentives slow health worker migration? PPP-adjusted salary differentials in Zimbabwe’s donor-dependent health system

Abstract

BACKGROUND: Large-scale migration of health workers from low-income countries continues to undermine health system capacity, particularly in contexts characterised by fiscal constraint and donor dependence. While retention incentives are widely used to mitigate attrition, their ability to offset international wage differentials remains contested. Zimbabwe provides a salient case, having implemented a long-standing Health Worker Retention Scheme (HWRS), largely financed by external partners, to stabilise critical cadres within the public health sector. This study aimed to quantify PPP-adjusted international salary differentials for selected Zimbabwean health worker cadres and to assess the extent to which donor-financed retention incentives narrow these gaps. METHODS: This was a cross-country comparison of annual remuneration for three cadres: professional nurses, medical officers, and medical specialists, using a purchasing power parity (PPP) framework. Salaries in Zimbabwe, South Africa, the United Kingdom, and the United States were compiled from official public-sector pay schedules and adjusted using International Comparison Program (ICP) 2021 PPP conversion factors. Zimbabwean salaries were analysed under three scenarios: base salary; base salary plus USD-denominated Government of Zimbabwe (GOZ) allowances; and total remuneration including GOZ allowances and Global Fund-financed HWRS top-ups. PPP-adjusted salary gaps were calculated relative to Zimbabwean health workers' base salary. RESULTS: Combined USD-denominated Government of Zimbabwe allowances and Global Fund-financed HWRS top-ups substantially increased PPP-adjusted salaries across all cadres, more than doubling remuneration for medical officers and specialists and nearly tripling earnings for nurses. Despite these increases, PPP-adjusted salaries in South Africa, the United Kingdom, and the United States remained several multiples higher than those in Zimbabwe. CONCLUSION: Combined domestic and donor-financed retention incentives meaningfully improve Zimbabwe's relative salary position but do not fundamentally alter the international remuneration gradient that underpins health worker migration. In donor-dependent health systems, such schemes function as stabilising mechanisms rather than long-term solutions. Sustainable retention will require complementary strategies addressing career progression, working conditions, and the global governance of health worker mobility.