Incentive Packages for Health Workers, Selected Countries| Objectives | Incentives | Complementary measures | Constraints | Results |
| Recruiting and retaining staff in the country | Pay competitive salariesSFTRETInclude seniority awards in pay scales | Fiscal policies that increase the after-tax marginal value of salaries | Budget limitationsSFTRETLow public service salariesSFTRETPolicies to reduce salaries as a share of operating costs | Helped retain physicians in Bahrain |
| Allow after-hours private practice in public institutions | Service standards and controls to prevent reduced work effort in the public system | Work effort that may be concentrated in private practice, leading to a deterioration of quality in public practice | Considered successful in BahrainSFTRETIn some countries, resulted in deterioration of public systems where providers also engage in independent private practice (McPake and others 1999) |
| Tolerate informal payments | Not applicable | Informal charges that limit access and may impede reforms that involve formal user fees and exemptions | Resulted in widespread use of informal payments in Eastern and Central Europe, Sub-Saharan Africa, and some East Asian and Pacific countries (Balabanova and McKee 2003; Chakraborty and others 2002; Thompson and Witter 2000) |
| Recruiting and retaining staff in rural areas | Provide higher salaries or location allowances(Wibulpolprasert and Pengpaiboon 2003)SFTRETBase remuneration on workload | Decentralized administrationSFTRETFreedom to allocate institutional revenues or savings from operational efficiency to fund incentivesSFTRETImproved infrastructure and staff competence | Overall staff shortagesSFTRETBudget limitationsSFTRETProfessional and lifestyle disadvantagesSFTRETSmaller potential for earnings from private practice than in urban areasSFTRETConflicting financial incentives (for example, loss of housing allowance in Bangladesh)SFTRETRisks posed by internal conflicts and civil wars(for example, Colombia and Uganda) | Premium payments for working in rural areas found successful in Thailand(Wibulpolprasert and Pengpaiboon 2003) |
| Require service in defined areas as condition of licensing or specialty training | Consistent application of policies on transfers and tenure | Loss of confidence if health workers perceive the selection process as arbitrary | Aided retention of professionals in Ghana and Zimbabwe(Chimbari 2003) |
| Provide opportunities for government-sponsored further education | | Providers' concerns that a temporary posting may become indefinite | |
| Provide housing and good-quality educational opportunities for health workers' families | Adequate salary | Budget limitations | Found successful for nurses but not doctors in Nepal |
| Recruit trainees from rural areas | Emphasis on public health and family practice in training curricula | Traditionally, overrepresentation of urban area students in student populations | Found successful in Thailand |
| Enhancing the quality and availability of primary care | Provide training and promotion opportunities for nurses and medical auxiliariesSFTRETTrain multifunctional health workersSFTRETMobilize women volunteers from communities, traditional birth assistants, and local leaders | Clear job descriptions and criteria for promotion | Opposition by professional associations to expanded roles for multifunction health workers in NepalSFTRETLimited training capacity in Uganda | Resulted in successful retraining of health assistants and other health workers in rural areas in Nepal to make them eligible for promotionSFTRETResulted in regrading of state-certified nurses to state-registered nurses in Zimbabwe (Chimbari 2003; Pannarunothai, Boonpadung, and Kittidilokkul 2001) |
| Encouraging teaching and research and reducing the internal brain drain | Pay health workers more if they do not practice privately | None | Allowances perhaps uncompetitive with private practice earnings | In Nepal, found successful in basic medical sciences but resulted in massive resignations in clinical departmentsSFTRETUncommon incentive, although a few countries (for example, Thailand) do pay professional allowances or nonpractice allowances |
| Improving the quality of care | Specify clinical guidelines in provider contracts | Leadership role by professional organizations Inclusion in the curricula of medical schools | Vested interests of professional associationsSFTRETWeak peer review systemsSFTRETLow consumerism and weak advocacy | Uncommon in developing countriesSFTRETSome success recorded in Cambodia's contracting experiment |
| License institutions and professionals based on defined standardsSFTRETPass laws requiring the registration of drugs and other potentially dangerous substances | Tradition of professional self-regulationSFTRETAcceptance of civil and legal authority | Regulatory capture and a culture of self-protectionSFTRETLow capacity to enforce laws and regulations | Reduced number of hospitals and unqualified doctors in EstoniaSFTRETResulted in limited success according to evidence from most developing countries(Bhat 1996) |
