article · Health Policy and Planning
In the Democratic Republic of the Congo, where the state struggles to maintain a fully financed public workforce, health workers rely on fragmented income sources to secure their livelihoods. An investigation of 1,771 health workers across four provinces examined these revenue streams and their underlying determinants. For facility-based staff, excluding doctors, the primary source of earnings is a share of patient user fees. In contrast, personnel in health zone management teams depend heavily on per diems and top-ups provided by external agencies, with statutory government allowances playing a comparatively minor role. Total earnings systematically favour individuals working in urban centres, administrative roles, or positions of facility leadership. These disparities threaten staff motivation, performance, and equitable workforce deployment. Because health financing reforms alter worker livelihoods, policy implementation must be recognised as inherently political rather than merely technical.
Understanding how healthcare workers earn a living in fragile states is crucial for building resilient health systems. When public staff depend on user fees and donor subsidies rather than reliable state salaries, healthcare becomes less accessible and workers are disincentivised from serving in rural areas. Addressing these distortions helps policymakers improve staff retention, performance, and the equitable delivery of essential care.
The abstract does not indicate a commercial application pathway. The findings instead offer applied empirical evidence for international development organisations, government ministries, and health planners designing public sector payroll mechanisms, human resource policies, and donor incentive programmes in fragile environments.
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The financial remuneration of health workers (HWs) is a key concern to address human resources for health challenges. In low-income settings, the exploration of the sources of income available to HWs, their determinants and the livelihoods strategies that those remunerations entail are essential to gain a better understanding of the motivation of the workers and the effects on their performance and on service provision. This is even more relevant in a setting such as the DR Congo, characterized by the inability of the state to provide public services via a well-supported and financed public workforce. Based on a quantitative survey of 1771 HWs in four provinces of the DR Congo, this article looks at the level and the relative importance of each revenue. It finds that Congolese HWs earn their living from a variety of sources and enact different strategies for their financial survival. The main income is represented by the share of user fees for those employed in facilities, and per diems and top-ups from external agencies for those in Health Zone Management Teams (in both cases, with the exception of doctors), while governmental allowances are less relevant. The determinants at individual and facility level of the total income are also modelled, revealing that the distribution of most revenues systematically favours those working in already favourable conditions (urban facilities, administrative positions and positions of authority within facilities). This may impact negatively on the motivation and performance of HWs and on their distribution patters. Finally, our analysis highlights that, as health financing and health workforce reforms modify the livelihood opportunities of HWs, their design and implementation go beyond technical aspects and are unavoidably political. A better consideration of these issues is necessary to propose contextually grounded and politically savvy approaches to reform in the DR Congo.
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DOI: 10.1093/heapol/czv131
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