The weak link between public spending in health and education, and health and education outcomes can be partially explained by the fact that the delivery of services that are critical to human development -- health, education, water and sanitation -- are widely failing poor people. The money is often spent on private goods or on the non-poor; it often fails to reach the frontline service provider; incentives for service delivery by providers are weak; and poor people sometimes fail to demand these services. This paper examines the experience with alternative mechanisms for service delivery -- contracting out to the private and NGO sectors, community participation, co-financing by service beneficiaries -- and shows that this, as well as the experience of more traditional public sector provision, can be interpreted by looking at three principal-agent relationships in the service-delivery chain: between policymakers and providers; between clients and providers; and between clients (as citizens) and policymakers. Weaknesses in one or more of these relationships can lead to service-delivery failure, while attempts to strengthen one may not always work because of deficiencies in other links in the chain. Copyright 2004, Oxford University Press.

Making Services Work for Poor People

Access to good-quality health services is crucial for the improvement of many health outcomes, such as those targeted by the Millennium Development Goals (MDGs) adopted by the international community in 2000. The health-related MDGs cannot be achieved if vulnerable populations do not have access to skilled personnel and to other necessary inputs. This paper focuses on the geographical dimension of access and on one of its critical determinants: the availability of qualified personnel. The objective of this paper is to offer a better understanding of the determinants of geographical imbalances in the distribution of health personnel, and to identify and assess the strategies developed to correct them. It reviews the recent literature on determinants, barriers and the effects of strategies that attempted to correct geographical imbalances, with a focus on empirical studies from developing and developed countries. An analysis of determinants of success and failures of strategies implemented, and a summary of lessons learnt, is included.

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Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce.

This paper reports on income generation practices among civil servants in the health sector, with a particular emphasis on dual practice. It first approaches the subject of public–private overlap. Thereafter it focuses on coping strategies in general and then on dual practice in particular.

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Dual practice in the health sector: review of the evidence.

Health sector workers respond to inadequate salaries and working conditions by developing various individual ''coping strategies'' — some, but not all, of which are of a predatory nature. The paper reviews what is known about these practices and their potential consequences (competition for time, brain drain and conflicts of interest). By and large, governments have rarely been proactive in dealing with such problems, mainly because of their reluctance to address the issue openly. The effectiveness of many of these piecemeal reactions, particularly attempts to prohibit personnel from developing individual coping strategies, has been disappointing. The paper argues that a more proactive approach is required. Governments will need to recognize the dimension of the phenomenon and systematically assess the consequences of policy initiatives on the situation and behaviour of the individuals that make up their workforce. Keywords Health personnel/economics; Public sector; Salaries and fringe benefits; Ethics; Job satisfaction; Adaptation, Psychological; Emigration and immigration; Career mobility; Motivation; Employee incentive plans; Socioeconomic factors (source: MeSH, NLM ). Mots clesPersonnel sanitaire/economie; Secteur public; Salaire et prime; Ethique; Satisfaction professionnelle; Adaptation psychologique; Emigration et immigration; Mobiliteprofessionnelle; Motivation; Plan pour ameliorer efficaciteet productivite ´ ; Facteur socio-economique (source: MeSH, INSERM ). Palabras clave Personal de salud/economo´a; Sector publico; Salarios y beneficios; Etica; Satisfaccion en el trabajo; Adaptacion psicologica; Migracion internacional; Movilidad laboral; Motivacion; Planes para motivacion del personal; Factores socioeconomicos (fuente: DeCS, BIREME ).

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When staff is underpaid: dealing with the individual coping strategies of health personnel

Insufficient attention has been paid to understanding what determines the performance of health workers and how they make labor market choices. This paper reports on findings from focus group discussions with both health workers and users of health services in Ethiopia, a country with some of the poorest health outcomes in the world. We describe performance problems identified by both health users and health workers participating in the focus group discussions, including absenteeism and shirking, pilfering drugs and materials, informal health care provision and illicit charging, and corruption. In the second part of the paper we present four structural reasons why these problems arise: (i) the ongoing transition from a health sector dominated by the public sector, toward a more mixed model; (ii) the failure of government policies to keep pace with the transition toward a mixed model of service delivery; (iii) weak accountability mechanisms and the erosion of professional norms in the health sector; and (iv) the impact of HIV/AIDS. The discussions underline the need to base policies on a micro-analysis of how health workers make constrained choices, both in their career and in their day to day professional activities.

https://papers.ssrn.com/sol3/Delivery.cfm/SSRN_ID708424_code427206.pdf?abstractid=708424&mirid=1

The Performance of Health Workers in Ethiopia: Results from Qualitative Research

OBJECTIVE To explore the type of private practice supplementary income-generating activities of public sector doctors in the Portuguese-speaking African countries, and also to discover the motivations and the reasons why doctors have not made a complete move out of public service. DESIGN Cross-sectional qualitative survey. SUBJECTS In 1996, 28 Angolan doctors, 26 from Guinea-Bissau, 11 from Mozambique and three from S Tome and Principe answered a self-administered questionnaire. RESULTS All doctors, except one unemployed, were government employees. Forty-three of the 68 doctors that answered the questionnaire reported an income-generating activity other than the one reported as principal. Of all the activities mentioned, the ones of major economic importance were: public sector medical care, private medical care, commercial activities, agricultural activities and university teaching. The two outstanding reasons why they engage in their various side-activities are 'to meet the cost of living' and 'to support the extended family'. Public sector salaries are supplemented by private practice. Interviewees estimated the time a family could survive on their public sector salary at seven days (median value). The public sector salary still provides most of the interviewees income (median 55%) for the rural doctors, but has become marginal for those in the urban areas (median 10%). For the latter, private practice has become of paramount importance (median 65%). For 26 respondents, the median equivalent of one month's public sector salary could be generated by seven hours of private practice. Nevertheless, being a civil servant was important in terms of job security, and credibility as a doctor. The social contacts and public service gave access to power centres and resources, through which other coping strategies could be developed. The expectations regarding the professional future and regarding the health systems future were related mostly to health personnel issues. CONCLUSION The variable response rate per question reflects some resistance to discuss some of the issues, particularly those related to income. Nevertheless, these studies may provide an indication of what is happening in professional medical circles in response to the inability of the public sector to sustain a credible system of health care delivery. There can be no doubt that for these doctors the notion of a doctor as a full-time civil-servant is a thing of the past. Switching between public and private is now a fact of life.

Francisco Dias

Papers

How and why public sector doctors engage in private practice in Portuguese-speaking African countries.