Fiscal Issues in Scaling Up the Health Workforce
99
100 90 80 70 60 50 40 30 20 10 0 Be Bo laru ts s w an Br a Bu azil Eg yp C lga t, am ria Ar b ab od Re ia In p. do of ne s Ke ia Le ny M ba a ad no ag n as c M ar ex M ico o Ni roc ca co ra Pa gua k Ph is ilip tan pi Rw nes an Tu da rk ey
Employee distribution (%)
Figure 6.3 Distribution of Civil Service Employees by Sector
other
education
health
Source: Vujicic, Ohiri, and Sparkes 2009. Note: For all levels of government.
increased hiring in the health sector spills over into education and other sectors, the fiscal implications become substantial. In Ghana, initially exceptional increases in pay for medical doctors were soon followed by increases for nurses, then teachers. The simulations for Kenya and Zambia show that if hiring in the education sector also increased, the overall wage bill would spike by a much larger amount. The situation is different where local governments or facilities receive a block grant accounted as a transfer. Because health worker wages are not directly budgeted and accounted for within the overall wage bill, wage bill policies and the health workforce are not directly linked. Operating units (either facilities or local government entities) have significant autonomy over allocating their budgets across wage and nonwage items. They also have flexibility to channel funds from various sources, including facility revenues, to wages. Expanding the health workforce in the facility model requires larger budgets for operating units. Additional funds may come from the government or other sources, including insurance, user fees, and donors. By mobilizing funds from nongovernment sources in autonomous units, health systems can raise expenditures without affecting the overall wage bill. In this case the health workforce is not part of the civil service, and