Assessing the disparity between health workers’ salaries and expenditures, and coping mechanisms adopted in hard to reach health facilities: A case of Kanungu District
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Background: Globally, studies have shown that HWs suffer from low wages and poor working conditions, and therefore dissatisfied with their jobs. In Uganda, it is common for HWs to go unpaid for up to three months, and not surprising that after completing their studies, many health professionals move to neighbouring countries like Kenya, Rwanda and South Africa where salaries can be up to seven times more. The recent export of HWs to Canada, Trinidad and UK is clear evidence of HWs’ search for jobs with better pay. Many HWs leave the country for better paying jobs and those that choose to remain and serve, majority engage in additional earning activities to deal with the low salaries. In the past, government has increased salaries of HWs, but HWs have never been satisfied with their pay. They respond to inadequate salaries in ways that manifest as various coping mechanisms to supplement their salaries to live closer to their desired standard of comfort. The question of how to structure payments for HWs to encourage better performance is one that is currently generating considerable interest in the country but unless government efforts to increase HWs salaries are to a level where HWs’ expenditure on basic necessities is addressed, HWs will always consider their salaries insufficient. Objectives: The study assessed the disparity between HWs’ salaries and monthly expenditures, the various predatory and non-predatory coping mechanisms adopted by different HW types to deal with the perceived low salaries, factors associated with engagement in the various coping mechanisms and the consequences of HWs’ engagement in coping mechanism. Methods: The study adopted a descriptive cross-sectional study, which was conducted among HWs in government and PNFP health facilities in Kanungu district using both qualitative and quantitative methods of data collection. Quantitatively, data was collected from 277 HWs through semi structured interviews while qualitatively; seven (7) KIIs were conducted with members of the DHT and facility managers/ in-charges. A total of 4 FGDs were also conducted with HWs to further explore their opinions about the salaries they receive and the various strategies they adopt to deal with the perceived low salaries for the purpose of triangulation. Data generated was analysed using bivariate and multivariate data analysis techniques. Results: Net salaries ranged from $291-$606 for medical officers, $76-$173 for enrolled nurses, $103-$218 for pharmacists, $61-$227 for lab staff, $211-$364 for clinical officers, $127-$297 for registered nurses and $55-$133 for nursing assistants. The total monthly expenditure of HWs ranged from $47 to $690, with an average of $245 (SD= $115). From the pattern of HWs’ expenditure, major expenses mainly occurred in terms of school fees, dependants and feeding. High expenditures were noticeable among medical officers, clinical officers and Registered Nurses. Results indicate a considerable disparity between HWs’ salaries and their household expenditure, only 23.8% (n= 66) had their expenditure within their salary. The salary expenditure disparity is more pronounced among nursing assistant, enrolled nurses and laboratory staff. The majority of HWs did not consider their salary sufficient, only 48 (17.3%) were satisfied with their remuneration, policy makers and facility managers did not differ in opinion. Health workers highlighted the average sufficient salary to be $960 (SD= $78) for medical officers, $210 (SD= $68) for enrolled nurses, $253 (SD= $122) for pharmacists, $252 (SD= $144) for lab staff, $389 (SD= $109) for clinical officers, $394 (SD= $172) for registered nurses and $149 (SD= $25) for nursing assistants. At least 2 in every 5 respondents practiced some form of coping mechanism, with HWs practising more of non-predatory mechanisms in dealing with the perceived low salaries. Non-predatory coping activities were practised across all HW types while predatory coping mechanisms (i.e. missing work attending to private business, giving priority to relatives while treating patients, referring patients to seek private services and treating patients at home for a fee) were highly prevalent among clinical officers, registered nurses and enrolled nurses. Household size and level of care were associated with engaging in coping mechanisms. The majority of the respondents affirmed that engaging in additional earning activities not only increases absence of HWs at the facilities (70%, n= 191) but also reduces staff productivity (67.9%, n= 188). Conclusion and Recommendations: With their current salaries, it is unavoidable for HWs to seize opportunities that could be more rewarding professionally and financially while maintaining their current jobs. Therefore, policy makers and planners at national level should ensure that the salary expenditure asymmetry of HWs is used as a basis to inform future salary increment initiatives for HWs by the government. Facility managers need to review incentives and allowances provided to clinical officers, registered nurses and enrolled nurses since predatory mechanisms are highly predominant among these cadres; they should also spearhead initiatives to form facility based savings schemes so that HWs can access financial assistance at low interest rates and also ensure that facilities introduce results-oriented management to ensure value for money from HWs so that they don’t compromise the work they are paid for while looking for additional incomes. The evidence of on-going extra earning activities highlights the necessity of ensuring that vigilant monitoring activities are put in place to discourage illegal practice, thus the need to implement rigorous systems of control and management, improve surveillance and on-spot supervision, and improve management of pharmaceuticals.