Understanding the levers: a new approach to managing health workers for better outcomes

There is a growing consensus that health workers are essential to health service delivery in developing countries. Yet the lack of an adequate framework for understanding their performance and labour market choices means that policy-makers often struggle to achieve their objectives.

One of the problems is that the empirical research on which policymakers often base their decisions has tended to focus on ‘extrinsic incentives’ such as salaries and other economic benefits. However reent research has shown that health workers take a much broader set of incentives into account. These include job attributes like access to training, opportunities for career progression and the scope for taking on a second job when choosing which job to take. Then there are more general considerations: does the area offer quality housing, decent food markets and access to good schools? Analytical tools such as discrete choice experiments allow us to quantify the relative importance of each of these attributes for job choices. Armed with these insights policy-makers can pick and choose from a large set of job attributes to make some jobs, for example those in rural areas, more attractive.

Monitoring is also vital for managing health worker performance. But the nature of the work – health workers often carry out a very wide range of tasks – makes effective monitoring a challenge, and one that is even more daunting in remote areas. Performance pay is one approach, but this often encourages a focus on outputs rather than quality of work. Community monitoring offers more direct accountability, but requires capacity in community to make this work.

The norms that shape a health organisation’s culture need to been taken into account when attempting to influence health workers’ attitudes and performance. Health workers operating in a culture of poor performance are more likely to perform badly; the opposite is also true, regardless of financial incentives. Public sector organisations with strong workplace norms will often expect their staff to display high levels of 'serving the public interest', while private sector organisations may strive to be highly patient-focussed because it will maximise client satisfaction levels and thus financial reward.

The desire to provide medical care for its own sake, regardless of earnings or social status, is often referred to in terms like ‘commitment’ and ‘vocation’ and has a powerful impact on both performance and career choice. Such ‘intrinsic' motivation is hard to measure, but it is important that institutions understand and acknowledge it. More critically, it is essential to view health works’ performance and work choices through a framework that takes into account both the extrinsic and intrinsic incentives; extrinsic incentives overlap with and can either strengthen – or undermine - health workers intrinsic motivations.

OPM applied such a framework that recognises the role of extrinsic and intrinsic motivations, together with monitoring and workplace norms, to practical human resource policy questions in many countries. In Cambodia, for example, a series of scenarios were used to help the ministry  better understand how they could attract – and keep – high-calibre health workers into rural jobs. Starting from a baseline salary of US$45, around 25 per cent of workers would choose a rural job. Increase the salary to US$70, and the proportion rises to 30 per cent. With a salary of US$70 plus good facilities, housing and promotion opportunities, almost 80 per cent of nurses would take a rural job – far more than if they were simply offered a much higher salary.