Salary delays among public sector primary care workers: evidence from facility surveys across 16 low- and middle-income countries

Background Primary healthcare is crucial for universal health coverage in low- and middle-income countries. While research on improving workforce performance has focused on training and incentives, the impact of basic payment system functions remains underexplored. This study investigates salary delays among public-sector primary care workers across 16 low- and middle-income countries and the association of delays with worker outcomes. Methods We analysed data from World Bank Service Delivery Indicators and Health Results-Based Financing surveys (2010–2018), covering 22 003 primary care workers from 8301 public-sector facilities. Salary delay was defined as any self-reported delay in receiving the previous month’s base salary. We examined patterns of delays and their associations with worker motivation, satisfaction and performance using fixed-effects linear probability models. Findings On average, 37% of health workers experienced salary delays, ranging from 2% to 83% across countries, primarily due to funding shortages and administrative issues. Delays were more common among workers without formal contracts and in rural or lower-level facilities. Experiencing a salary delay was associated with a 3.1 percentage point (pp) lower probability of being satisfied with one’s salary (95% CI −5.7 to −0.5), a 4.6 pp lower probability of feeling motivated (95% CI −7.0 to −2.3), a 1.9 pp higher probability of unauthorised absence (95% CI +0.3 to +3.5) and a 5.6 pp higher probability of outside employment (95% CI +2.5 to +8.6). Interpretation Salary delays are prevalent among public primary healthcare workers in resource-poor settings, affecting vulnerable groups and associated with negative worker outcomes. Addressing delays requires diagnosing bottlenecks across administrative tiers, improving cash-to-payroll execution and allocating resources equitably to settings and worker groups where delays are most concentrated. Future work should examine payment processes across administrative levels and incorporate routine measurement of salary timeliness to support accountability and inform targeted strategies to reduce delays.