Global Poverty Research Group

Health workers in Ethiopia

The research question

This project studies the labour market for health workers. Our aim is to get a better understanding of the role of human resources in the health sector. The skills and motivation of health workers form the foundation for health service delivery. Human resources are important from a budgetary perspective, typically accounting for more than half of government spending on health.

Initially the project will focus on Ethiopia where health outcomes and health service indicators are among the worst in the world and problems of health worker motivation are often cited as the reason.

In the first phase of the project we explored a broad range of issues. Qualitative methods were used to identify key hypotheses and areas of focus for further work, and to understand the nature and relative importance of different labour market issues. The preparatory work consisted of three sets of activities. First, a desk-based preparation included a review of relevant literature and policy documents, and the design of tools for expert interviews, focus group discussions, and experimental games. Second, the team conducted a mission to Ethiopia.  Thirty two experts were interviewed, including government officials at different levels, head of professional associations, health care providers themselves and academics.  Nine focus group discussions were conducted with health workers and users in both the capital and a regional town.  Finally an experimental game with nursing students was conducted.  Based on our findings during this mission, a proposal for a quantitative survey with health workers was drafted.  The quantitative survey is currently under preparation.  Below we briefly discuss some of the results from the qualitative and experimental pre-research.

Results from Focus Group Discussion:

We held three group discussions with (i) medical doctors, specialist and health officers; (ii) nurses and midwifes; and (ii) health assistants, both in the capital and a provincial town.  We also held group discussions with users: in the provincial town one, in the capital two, one with relatively well off users - who restrict themselves to private health care and one with relatively poorer users, who use mostly public facilities. 

We found that the recent privatization has a strong impact on how health workers behave at the micro level, and on their perceptions.  Here, we restrict ourselves to a few key findings and provide some quotes which reflect the participants’ dominant views.

Users argue that there is a need for politeness and respect from health workers.  They say that although health workers may have the skills, they often do not apply them, especially in the public sector.   The likely reason for this is that the majority of health workers are dissatisfied with their jobs.   This dissatisfaction is not just focused on salaries.  As Table 1 shows, health workers associate the public and private sector with different job attributes. 

Table 1

health workers’ Perceptions of public and private sector

Public Sector

Private Sector

Low pay

Good paid

Work time restrictions

Hard work

No resources

Resources

Training opportunities

No training

Job security

No job security

Bureaucracy

Profit driven

It is not surprising that the ideal job from a health worker’s perspective combines work in both sectors.  This provides the perfect ‘portfolio’. As one health worker said

“I would recommend a person to combine a public and private sector job because the public sector has several limitations.  We can apply what we have learned in the private sector, as there is a good supply of materials and facilities.” 

We find that important aspects of health workers’ behaviour can be explained by aspiring to combine work in both sectors.  Absenteeism and shirking seem largely a consequence of people combining work in both sectors.  If health workers do not manage to get a formal private sector job, they engage in informal private health care activities. These seem to be common practice.  As one health assistant puts it:

“Nurses give injections at home.  Most of the time it is the patient who has to buy the medicine and the nurses provide injections and change the dressing.  In some cases they also prescribe. …  They provide a good service. …  They are approached very informally.”

Health workers argued that inappropriate behaviour like embezzlement and extortion are common place, but not on a large organized scale.  We found that overcharging and favoritism, as well as taking drugs and equipment out of the public facilities for private use are also common.

Results from Experimental Game

Embezzlement of resources is hampering public service delivery throughout the developing world. Research on the behavioural patterns underlying this issue is hindered by problems of measurement. To overcome these problems we used an economic experiment to investigate the determinants of corrupt behaviour. We focused on three aspects of behaviour: (i) embezzlement by public servants; (ii) monitoring effort by designated monitors; and, (iii) voting by community members when provided with an opportunity to select a monitor. The experiment allowed us to study the effect of wages, effort observability, rules for monitor assignment, and professional norms. Our experimental subjects were Ethiopian nursing students.

We found that service providers who earn more embezzle less, although the effect is small. Embezzlement is also lower when observability (associated with the risk of being caught and sanctioned) is high, and when service providers face an elected rather than randomly selected monitor. Monitors put more effort into monitoring, when they face re-election and when the public servant receives a higher wage. Communities re-elect monitors who put more effort into exposing embezzlement. Framing — whereby players are referred to as “health workers” and “community members” rather than by abstract labels — affects neither mean embezzlement nor mean monitoring effort, but significantly increases the variance in both. This suggests that different types of experimental subject respond differently to the framing, possibly because they adhere to different norms.

Figure 1 contains a histogram of the resources retained or embezzled by the ‘health worker’ in the games (192 rounds in total). The distribution of embezzlement has a single mode at one tile.  In over one fifth of the rounds no tiles were retained, while in a similar proportion two were retained, and in nearly a quarter three or more tiles were retained. The mean number of tiles retained was 1.61, but varies across treatments.

Figure 1

Resources retained by public service providers

Figure 2 displays the histograms and cumulative distributions of the numbers of tiles retained under the different treatments.  Starting at the top of Figure 2 we see that when the monitors were randomly selected the ‘health workers’ retained more tiles than when the monitors were elected. The mean numbers of tiles retained were 1.96 and 1.27 respectively. The second row of graphs in Figure 2 indicates that observability also had an impact. When observability was high health workers retained fewer tiles than when it was low. The mean numbers of tiles retained were 1.36 and 1.86 respectively. The third row of graphs in Figure 6 indicates that when health workers were paid more they retained fewer tiles. The mean numbers of tiles retained in the low and high wage treatments were 1.90 and 1.33 respectively. Finally, the effects of framing are complex. The mean numbers of tiles retained in the abstract and framed treatments were very similar, 1.66 and 1.57 respectively, even though the modes were distinct at one and zero. However, framing significantly increases (5 percent level) the variance in behaviour.

Figure 2

Resources retained by ‘public service providers’ under different treatments


Regression analyses add further support to these findings.

For a full description of the game and the results relating to embezzlement, monitoring and voting see Barr, Lindelow and Serneels (2003).

Recent publications

Barr A., M. Lindelow, P. Serneels, 2003, “To Serve the Community or One self: The Public Servant’s Dilemma”, CSAE Working Paper, forthcoming.

Lindelow M, P. Serneels, 2003, “The Best of Both Worlds: Health Workers in the Public and Private Sector”, World Bank Research Paper, forthcoming.

Reseachers to contact for this project

Abigail Barr (CSAE)

Magnus Lindelow (Development Economics Research Group World Bank)

Pieter Serneels (CSAE)

Funding:  The World Bank