Human Resources for Health in Maternal, Neonatal and - HRH ...

al. 2008). Dual practice is another approach where clinicians combine salaried, public-sector
clinical work with a fee-for-service private clientele (Ferrinho, Van Lerberghe et al. 2004).
This private practice may erode the quality of public services, be illegal and involve
corruption. A village-based health survey in Vietnam found for example found that 70% of
the drug sellers were also working as government workers and using their links to the health
system to purchases drugs (Chen 1994). This raises questions concerning health worker
performance and what constitutes the right balance between financial and non financial
incentives that are required to achieve and maintain quality practice.
Incentives
Incentives involve the development of additional inputs to improve retention of staff and
attract staff to jobs at community level and to improve performance. Recruiting and
maintaining health workers at community level particularly in rural and remote areas is
challenging. This is identified in the Kampala Declaration, that called on governments to
"assure adequate incentives and an enabling and safe working environment for effective
retention and equitable distribution of the health workforce" (GHWA 2008). In response to
this the WHO has established a special programme on improving retention of health workers
in rural and remote areas and guidelines on incentives for the retention and recruitment of
health professionals have been published (GHWA 2008). The development of effective
incentives schemes/motivation mechanisms for community health workers is also one of the
nine key strategic action areas that SEARO member countries have pledged to focus on
(WHO/SEARO 2008).
Inventiveness can be provided at the individual health worker level, health facility level or
health system level (Dieleman 2006). They have been classified into direct (e.g. subsidized
education, additional leave, insurance benefits) and indirect (e.g. better working conditions,
access to professional support network, greater participation in decision-making bodies). In
addition non financial incentives have been divided into those which concern management
and the supportive environment, regulatory interventions, educational interventions (Dolea
2009). Henderson and Tulloch describe various approaches to incentives including those that
are performance based, those that are designed to encourage return migration and restrictive
measures and sanctions (Henderson 2008). These various types and approaches to
encouraging the workforce may be employed as separate strategies or packaged together in
various configurations to maximise impact. The success of incentives to enable health
workers to meet their personal and the organizational goals is highly dependent on the
context in which they are delivered and the motivations of health personnel.
Mathauer and Imhoff provide a useful conceptual framework for understanding the factors
that determine motivation and identifying what areas might be targeted using incentives in
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