Health Systems: principled integrated care an overall strengthening of health care systems based on primary health care principles The Khayelitsha antiretroviral programme uses a nurse-based service model and relies on strong community mobilization for peer support. It has shown that HIV/AIDS treatment can be rolled out most effectively if: the entire health system is mobilized and HIviaIdS treatment activities are integrated into the basic package of care; treatment services are decentralized to ensure coverage and community involvement; treatment and care are part of a continuum of care" supported by a facility-linked home- based care system and a referral system. The additional resources that must flow into countries'health sectors to support HIV/AIDS control efforts, including 3 by 5", can be used in ways that will strengthen health systems horizontally. Developing context-specific strategies to achieve this will be part of WHO technical collaboration with countries. Similarly, if the recommendations of the Commis sion on Macroeconomics and Health for large increases in global investment in health are followed by the international community, the coming years will offer a crucial opportunity for development of health systems that are led by primary health care. Enormous obstacles to the scale-up of health systems based on primary health care persist In some countries, violent conflicts and other emergencies have seriously damaged health sys- tems(see Box 7.3). Multiple forms of inefficiency undermine systems, such as government health expenditure disproportionately devoted to tertiary care and programmes that do not focus on a significant burden of disease(11). Lack of financial resources remains a funda- mental problem. Total health expenditure is still less than US$ 15 per capita in almost 20% of Box 7.3 Rebuilding Iraqs health sector The Gulf War of 1991 and the economic sanctions marked the start of undertake essential public health functions; lack of a package of health the decline of a health care delivery system that had been a model for services that includes catastrophic care in the event of emergency and the region during the 1980s Health indicators dropped to levels com- diagnostic and laboratory facilities; external brain drain of human re- arable to some of the least developed countries: in 1996, infant, child, sources: lack of an information system for informed decisions at the and maternal mortality rates were estimated at 100/1000, 120/1000, policy and implementation levels; inadequate finandal resources and and 300/100 000 live births, respectively, a twofold increase over 1990 unclear mechanisms for smooth flow of funds to meet the investment levels. The Oil for Food programme brought a relative improvement of and operational costs of the system; and the need for improved coordi the health of Iraqi people, although still far from pre-1990 levels. Health nation among all stakeholders in health to optimize donated resources. outcomes are now among the poorest in the region nior staff from the Ministry of Health, officials from the Coali. aq is below the regional average in terms of physicians to popu- tion Provisional Authority, and representatives of organizations of the lation(5.3 doctors per 10 000 population in 2002): there are too many United Nations system, nongovernmental organizations and donors met pecialists but too few primary health doctors and nurses. Following the in Baghdad in August 2003 to determine immediate and medium-term 2003 war, the health infrastructure, which had suffered from years of priorities to enable the health sector to provide health services that are disrepair, was further weakened by the widespread looting, inadequate accessible, equitable, affordable and of adequate quality electricity and water supply, and institutional instability. Re-establishing the functioning of the health sector to pre-war The pre-2003 war health system was hospital-based and driven levels requires funds for salaries and other priority recurrent expendi by curative care, and did not respond adequately to health needs. The ture. It is estimated that lraq's financial requirements for health services challenge for Iraqi policy-makers and the donor community is to in 2004-from government and donor sources-will be in the order of inefficient and inadequate health services to a system based on primary and increasing income, the projections for the period 2004-2007 are in care, prevention, and evidence-based policy. The new system should the range of USS 3. 7-7.8 billion, which at the end of the period trans. tackle the disease burden faced by Iraq's people and be affordable within late into a per capita public expenditure of USS 40-84. Forecasting the available envelope of public finance economic performance, fiscal capacity and donors' willingness to sus. Major challenges face the health sector: limited capacity of tain lrag for the period 2004-2007, however, is an exercise fraught the Ministry of Health (and health directorates in governorates)to with difficulties
Health Systems: principled integrated care 109 – an overall strengthening of health care systems based on primary health care principles. The Khayelitsha antiretroviral programme uses a nurse-based service model and relies on strong community mobilization for peer support. It has shown that HIV/AIDS treatment can be rolled out most effectively if: – the entire health system is mobilized and HIV/AIDS treatment activities are integrated into the basic package of care; – treatment services are decentralized to ensure coverage and community involvement; – treatment and care are part of a “continuum of care” supported by a facility-linked homebased care system and a referral system. The additional resources that must flow into countries’ health sectors to support HIV/AIDS control efforts, including “3 by 5”, can be used in ways that will strengthen health systems horizontally. Developing context-specific strategies to achieve this will be part of WHO’s technical collaboration with countries. Similarly, if the recommendations of the Commission on Macroeconomics and Health for large increases in global investment in health are followed by the international community, the coming years will offer a crucial opportunity for development of health systems that are led by primary health care. Enormous obstacles to the scale-up of health systems based on primary health care persist. In some countries, violent conflicts and other emergencies have seriously damaged health systems (see Box 7.3). Multiple forms of inefficiency undermine systems, such as government health expenditure disproportionately devoted to tertiary care and programmes that do not focus on a significant burden of disease (11). Lack of financial resources remains a fundamental problem. Total health expenditure is still less than US$ 15 per capita in almost 20% of Box 7.3 Rebuilding Iraq’s health sector The Gulf War of 1991 and the economic sanctions marked the start of the decline of a health care delivery system that had been a model for the region during the 1980s. Health indicators dropped to levels comparable to some of the least developed countries: in 1996, infant, child, and maternal mortality rates were estimated at 100/1000, 120/1000, and 300/100 000 live births, respectively, a twofold increase over 1990 levels. The Oil for Food programme brought a relative improvement of the health of Iraqi people, although still far from pre-1990 levels. Health outcomes are now among the poorest in the region. Iraq is below the regional average in terms of physicians to population (5.3 doctors per 10 000 population in 2002); there are too many specialists but too few primary health doctors and nurses. Following the 2003 war, the health infrastructure, which had suffered from years of disrepair, was further weakened by the widespread looting, inadequate electricity and water supply, and institutional instability. The pre-2003 war health system was hospital-based and driven by curative care, and did not respond adequately to health needs. The challenge for Iraqi policy-makers and the donor community is to re-establish basic services in the short term while transforming the inefficient and inadequate health services to a system based on primary care, prevention, and evidence-based policy. The new system should tackle the disease burden faced by Iraq’s people and be affordable within the available envelope of public finance. Major challenges face the health sector: limited capacity of the Ministry of Health (and health directorates in governorates) to undertake essential public health functions; lack of a package of health services that includes catastrophic care in the event of emergency and diagnostic and laboratory facilities; external brain drain of human resources; lack of an information system for informed decisions at the policy and implementation levels; inadequate financial resources and unclear mechanisms for smooth flow of funds to meet the investment and operational costs of the system; and the need for improved coordination among all stakeholders in health to optimize donated resources. Senior staff from the Ministry of Health, officials from the Coalition Provisional Authority, and representatives of organizations of the United Nations system, nongovernmental organizations and donors met in Baghdad in August 2003 to determine immediate and medium-term priorities to enable the health sector to provide health services that are accessible, equitable, affordable and of adequate quality. Re-establishing the functioning of the health sector to pre-war levels requires funds for salaries and other priority recurrent expenditure. It is estimated that Iraq’s financial requirements for health services in 2004 – from government and donor sources – will be in the order of US$ 0.8–1.6 billion (or US$ 33–66 per capita). Assuming a sustained and increasing income, the projections for the period 2004–2007 are in the range of US$ 3.7–7.8 billion, which at the end of the period translate into a per capita public expenditure of US$ 40–84. Forecasting economic performance, fiscal capacity and donors’ willingness to sustain Iraq for the period 2004–2007, however, is an exercise fraught with difficulties
110 The World Health Report 2003 WHO Member States. In many countries, especially the poorest, people in need of treatment for themselves or their families still pay for the bulk of health services out of pocke All efforts to improve health care systems in developing countries must confront several main challenges: workforce development and retention; health information management; financ ing; and government stewardship within a pluralistic health landscape. The remaining sec tions of this chapter consider these topics. Systems face difficulties in numerous other areas as well, but all four of these problems demand urgent action in order to scale up the system to meet health targets. If constraints in these areas are not overcome, little progress will be made in improving access to care among the poorest. The global health workforce crisis The most critical issue facing health care systems is the shortage of the people who make them work. Although this crisis is greatest in developing countries, particularly in sub-Saha- ran Africa, it affects all nations. It severely constrains the response to the aIds treatment emergency and the development of health systems driven by primary health care, even as AIDS reduces the available workforce. Botswana's commitment to provide free antiretroviral therapy to all eligible citizens is frustrated, not by financing, but by the severe lack of health personnel(12) Unfortunately, workforce issues are still considered to be relatively unimportant by both national governments and international agencies. Rapid and substantial strengthening of the workforce is urgently required to capitalize on the funds and pharmaceuticals that are The health workforce crisis has to be confronted in an economic and policy environment very different from that of 25 years ago. Traditional models in which the government directly recruits, trains, hires and deploys health professionals no longer reflect the reality of most developing countries. Most countries have undergone decentralization and reforms of the civil service and the health sector. There has been a great expansion in the health care roles of nongovernmental organizations and private providers. Furthermore, all countries are now part of the global marketplace for health professionals, and the effects of the demand-supply imbalance will only increase as trade in health services increases(13). Accordingly, new mod- els for health workforce strengthening must be developed and evaluated (14) Size, composition and distribution of the health workforce The number of health workers in a country is a key indicator of its capacity to scale up deli ery of interventions. This crisis is nowhere greater than in sub-Saharan Africa, where limita tions on staffing are now recognized as a major constraint to achieving national health goals and the MDGs(15). In Chad and the United Republic of Tanzania, for example, the current workforce is grossly insufficient for the extensive delivery of priority interventions(16).Coun tries facing such extreme personnel shortages urgently need a rapid increase in the numbers of health workers to perform key tasks, particularly the delivery of services at community level in underserved areas The number of health workers in a country is not the only determinant of access to primary health care. Figure 7. 1 shows that the number of births at which skilled attendants are present is only partially related to the number of health professionals in a country. Guinea, Indone- The term" health professionals"is defined for the WHO database as including physicians, nurses, midwives, dentists and pharmacists
110 The World Health Report 2003 WHO Member States. In many countries, especially the poorest, people in need of treatment for themselves or their families still pay for the bulk of health services out of pocket. All efforts to improve health care systems in developing countries must confront several main challenges: workforce development and retention; health information management; financing; and government stewardship within a pluralistic health landscape. The remaining sections of this chapter consider these topics. Systems face difficulties in numerous other areas as well, but all four of these problems demand urgent action in order to scale up the system to meet health targets. If constraints in these areas are not overcome, little progress will be made in improving access to care among the poorest. The global health workforce crisis The most critical issue facing health care systems is the shortage of the people who make them work. Although this crisis is greatest in developing countries, particularly in sub-Saharan Africa, it affects all nations. It severely constrains the response to the AIDS treatment emergency and the development of health systems driven by primary health care, even as AIDS reduces the available workforce. Botswana’s commitment to provide free antiretroviral therapy to all eligible citizens is frustrated, not by financing, but by the severe lack of health personnel (12). Unfortunately, workforce issues are still considered to be relatively unimportant by both national governments and international agencies. Rapid and substantial strengthening of the workforce is urgently required to capitalize on the funds and pharmaceuticals that are now available. The health workforce crisis has to be confronted in an economic and policy environment very different from that of 25 years ago. Traditional models in which the government directly recruits, trains, hires and deploys health professionals no longer reflect the reality of most developing countries. Most countries have undergone decentralization and reforms of the civil service and the health sector. There has been a great expansion in the health care roles of nongovernmental organizations and private providers. Furthermore, all countries are now part of the global marketplace for health professionals, and the effects of the demand–supply imbalance will only increase as trade in health services increases (13). Accordingly, new models for health workforce strengthening must be developed and evaluated (14). Size, composition and distribution of the health workforce The number of health workers in a country is a key indicator of its capacity to scale up delivery of interventions. This crisis is nowhere greater than in sub-Saharan Africa, where limitations on staffing are now recognized as a major constraint to achieving national health goals and the MDGs (15). In Chad and the United Republic of Tanzania, for example, the current workforce is grossly insufficient for the extensive delivery of priority interventions (16). Countries facing such extreme personnel shortages urgently need a rapid increase in the numbers of health workers to perform key tasks, particularly the delivery of services at community level in underserved areas. The number of health workers in a country is not the only determinant of access to primary health care. Figure 7.1 shows that the number of births at which skilled attendants are present is only partially related to the number of health professionals in a country.1 Guinea, Indone- 1 The term “health professionals” is defined for the WHO database as including physicians, nurses, midwives, dentists and pharmacists
Health Systems: principled integrated care 11 sia and Paraguay have similar workforce numbers but wide differences in the level of cover age. This is caused by several factors, including the skill mix of health workers, their geo- graphical and functional distribution, and their productivity. These data indicate the importance of using the existing workforce more effectively. Gender discrimination in the health professions has many serious implications for the long term strength of the health care system and especially for the delivery of services to poor and disadvantaged populations. A specific issue concerns the under-representation of women among those who manage and direct services, even though most health care workers are women. For example, in South Africa, men represent only 29% of personnel in administra tion overall, but they occupy 65% of all senior management posts(17). Without proper rep- resentation at the managerial and leadership levels, womens needs as employees within the health system will continue to be neglected. More generally, workforce policy and planning must consider gender and life-cycle issues, not only out of concern for equity, but also to enable efficient and effective development of a health care system that responds to and meets the particular needs of women Workforce training Meeting urgent health challenges while laying stronger foundations for health systems re- quires that health planners consider the composition of the health workforce in terms of training levels and skill categories. In developed countries, experimentation with new cat gories of health worker is a response to cost-containment and quality of care concerns. In developing countries such experimentation is a direct response to limited supply To achieve the goals associated with health care systems driven by primary health care, new options for the education and in-service training of health care workers are required so as to Figure 7.1 Relationship between births accompanied by skilled attendants and number of health professionals, a 33 developing and transition countries ◆ Brazil Namibia 50 Indonesia 30 Guinea ◆ Pakistan Density of physicians, nurses and midwives (per 100 000 population) WHO/UNICEF latest estimates
Health Systems: principled integrated care 111 sia and Paraguay have similar workforce numbers but wide differences in the level of coverage. This is caused by several factors, including the skill mix of health workers, their geographical and functional distribution, and their productivity. These data indicate the importance of using the existing workforce more effectively. Gender discrimination in the health professions has many serious implications for the longterm strength of the health care system and especially for the delivery of services to poor and disadvantaged populations. A specific issue concerns the under-representation of women among those who manage and direct services, even though most health care workers are women. For example, in South Africa, men represent only 29% of personnel in administration overall, but they occupy 65% of all senior management posts (17). Without proper representation at the managerial and leadership levels, women’s needs as employees within the health system will continue to be neglected. More generally, workforce policy and planning must consider gender and life-cycle issues, not only out of concern for equity, but also to enable efficient and effective development of a health care system that responds to and meets the particular needs of women. Workforce training Meeting urgent health challenges while laying stronger foundations for health systems requires that health planners consider the composition of the health workforce in terms of training levels and skill categories. In developed countries, experimentation with new categories of health worker is a response to cost-containment and quality of care concerns. In developing countries such experimentation is a direct response to limited supply. To achieve the goals associated with health care systems driven by primary health care, new options for the education and in-service training of health care workers are required so as to 0 100 200 300 400 500 600 Density of physicians, nurses and midwives (per 100 000 population) Percentage of deliveries assisted by skilled birth attendant aWHO/UNICEF latest estimates. 0 10 20 30 40 50 60 70 80 90 100 Figure 7.1 Relationship between births accompanied by skilled attendants and number of health professionals,a 33 developing and transition countries Nepal Pakistan Guinea Indonesia Paraguay Brazil Namibia Turkey Egypt
112 The World Health Report 2003 ensure a workforce more closely attuned to country needs. Training of students from devel- oping countries at high-prestige institutions in developed countries is useful only when th is no local or regional alternative. Although there are about twice as many nursing schools as medical schools worldwide, in the African Region there are 38 nursing schools and 64 medi- cal schools. This suggests that too many expensive health workers are produced in places that ight have a greater need for new types of providers with an education more focused on primary health care. The public health workforce also needs strengthening, based on a new approach to in-country or regional training that emphasizes the management of health prob- lems at the district level (18) The workforce of doctors is often complemented by training nurse practitioners,assistant nedical officers"and mid-level professionals. These categories are health professionals who can assume many of the responsibilities previously reserved for those with a full medical degree(see Box 7.4). For example, many studies in developed countries show that nurse prac- titioners can reduce the costs of care without harming, and sometimes actually improving, health outcomes(21, 22). In the Pacific Islands, mid-level practitioners, with various titl such as medex, health assistant, or health officer, play an important role in meeting curative and preventive needs, especially in remote or rural areas(23). In other countries, community health workers are trained in very specific and high-priority activities, making it possible to serve populations that are out of the reach of formal health care services. In the past, primary health care strategies based on community health workers or other alter- native health care providers have been difficult to sustain(24). However, evidence suggests that such strategies can be effective, given appropriate training(25, 26). To be successful, the creation of new types of health worker requires that they be valued for their distinctive con tribution, rather than treated as second-class providers. This means offering them career development prospects, rotation to and from rural and underserved areas, good working conditions, the chance to work as a team with other professionals, and an adequate salary. New cadres can be seen not only as a pragmatic response to current shortages, but as a cohort term to their incorporation in the more highly qualified professional categores. Evidences whose skills can be continually upgraded through in-service training, leading in the longe growing that community members can carry out a wide range of health care tasks, including treatment of more complex conditions(10, 25-28) Migration of health workers Policy-makers in all countries are concerned about"brain drain"of the health workforce within and between countries, although relevant research is still in its infancy (29). The move ment of health professionals closely follows the migration pattern of all professionals. while ox 7.4 Training assistant medical officers: the tecnicos of Mozambique In 1984, a three-year programme was initiated to create assistant medi- rty-six assistant medical officers were trained between 1984 and edures in remote areas where consultants were not available(19). The ing For example, a comparison of 1000 r on quality of care is promis. programme trains middle-level health workers in skills required for three conducted by tecnicos de cirurgia with the same number conducted by broad priority areas: pregnancy-related complications, trauma-related obstetricians or gynaecologists indicated that there were no differences complications and emergency inflammatory conditions. Two years of lec. in the outcomes of this type of delivery or in the associated surgical tures and practical sessions in the Maputo Central hospital are followed interventions (20). Many countries have now started or are considering by a one-year internship at a provincial hospital, under the direct super- similar programmes, based on their claimed cost-effectiveness. The vision of a surgeon. potential impact of this type of health worker on both quality and efficiency of health care must continue to be evaluated
112 The World Health Report 2003 ensure a workforce more closely attuned to country needs. Training of students from developing countries at high-prestige institutions in developed countries is useful only when there is no local or regional alternative. Although there are about twice as many nursing schools as medical schools worldwide, in the African Region there are 38 nursing schools and 64 medical schools. This suggests that too many expensive health workers are produced in places that might have a greater need for new types of providers with an education more focused on primary health care. The public health workforce also needs strengthening, based on a new approach to in-country or regional training that emphasizes the management of health problems at the district level (18). The workforce of doctors is often complemented by training nurse practitioners, “assistant medical officers” and mid-level professionals. These categories are health professionals who can assume many of the responsibilities previously reserved for those with a full medical degree (see Box 7.4). For example, many studies in developed countries show that nurse practitioners can reduce the costs of care without harming, and sometimes actually improving, health outcomes (21, 22). In the Pacific Islands, mid-level practitioners, with various titles such as medex, health assistant, or health officer, play an important role in meeting curative and preventive needs, especially in remote or rural areas (23). In other countries, community health workers are trained in very specific and high-priority activities, making it possible to serve populations that are out of the reach of formal health care services. In the past, primary health care strategies based on community health workers or other alternative health care providers have been difficult to sustain (24). However, evidence suggests that such strategies can be effective, given appropriate training (25, 26). To be successful, the creation of new types of health worker requires that they be valued for their distinctive contribution, rather than treated as second-class providers. This means offering them career development prospects, rotation to and from rural and underserved areas, good working conditions, the chance to work as a team with other professionals, and an adequate salary. New cadres can be seen not only as a pragmatic response to current shortages, but as a cohort whose skills can be continually upgraded through in-service training, leading in the longer term to their incorporation in the more highly qualified professional categories. Evidence is growing that community members can carry out a wide range of health care tasks, including treatment of more complex conditions (10, 25–28). Migration of health workers Policy-makers in all countries are concerned about “brain drain” of the health workforce within and between countries, although relevant research is still in its infancy (29). The movement of health professionals closely follows the migration pattern of all professionals. While Box 7.4 Training assistant medical officers: the técnicos of Mozambique In 1984, a three-year programme was initiated to create assistant medical officers (técnicos de cirurgia) to perform fairly advanced surgical procedures in remote areas where consultants were not available (19). The programme trains middle-level health workers in skills required for three broad priority areas: pregnancy-related complications, trauma-related complications and emergency inflammatory conditions. Two years of lectures and practical sessions in the Maputo Central hospital are followed by a one-year internship at a provincial hospital, under the direct supervision of a surgeon. Forty-six assistant medical officers were trained between 1984 and 1999, and the evaluation of their influence on quality of care is promising. For example, a comparison of 1000 consecutive caesarean sections conducted by técnicos de cirurgia with the same number conducted by obstetricians or gynaecologists indicated that there were no differences in the outcomes of this type of delivery or in the associated surgical interventions (20). Many countries have now started or are considering similar programmes, based on their claimed cost-effectiveness. The potential impact of this type of health worker on both quality and efficiency of health care must continue to be evaluated
Health Systems: principled integrated care doctors and nurses make up only a small proportion of professional migrants, their loss weak ns health systems. The internal movement of the workforce to urban areas is common to all countries within a region, there is also movement from poorer to richer countries, for example from Zambia to South Africa or from the United Republic of Tanzania to Botswana. The most controversial brain drain"is international professional migration from poorer to wealthier countries(30) While the departure of doctors receives the most attention, it is the departure of nurses and other health professionals that can easily cripple a health system. Nurses are in high demand in developed countries, partly because of population ageing. Some efforts have been made to promote ethical practices in international recruitment, but results have yet to be assessed (31) Workforce mobility creates additional imbalances just when increased financial resources are beginning to flow to some developing countries. This requires better workforce planning developed countries, attention to issues of pay and other rewards in developing countries, and improved management of the workforce in all countries Paying more and paying differently Raising wages may increase the number of health workers and their productivity and may succeed in countries where health workers are paid less than comparable professions. It may be less successful, however, in countries where health sector wages are higher than those of comparable professions. Wages take the single largest share of health expenditure, so increases have to be carefully evaluated for their impact both on the availability and productivity of health workers and on aggregate budgets. The role of public sector unions in negotiating with governments for pay increases is an additional complexity As well as raising salaries, other strategies to improve productivity include non-financial ben efits such as housing, electricity and telephones, on-the-job training with professional super- vision,and opportunities for rotation and promotion. In rural Senegal, providing nurses with motorcycles not only made it possible to increase immunization coverage but also im- proved their access to technical support and reduced their isolation(32) Both financial and non-financial incentives can also reduce geographical imbalances in the distribution of health workers. For example, in Indonesia, a bonus of as much as 100% of the normal salary attracted medical graduates from Jakarta to the outer islands(33). Recruit ment and training of people from remote areas, who are committed to their region of origin have also been proposed. Finally, nongovernmental organizations concerned with health and private providers are a large and increasing presence in most countries Governments could consider partnerships in which the public sector provides financial support and the nongovernmental organiza tions manage and provide the direct services. Often, private health workers are available in places that the public sector finds difficult to reach. In such situations, establishing formal programmes either to contract private providers or to reimburse the services they provide may be the most pragmatic response. In the mid-1990s, the Government of Guatemala was obliged to expand health care services to unserved populations as part of the negotiated peace agreements that took place at the time It contracted more than 100 nongovernmental or ganizations to provide basic health care services to some 3 million of the country's citizens, predominantly indigenous and rural people, who previously had no access to services(34) Recently, Cambodia has successfully experimented with contracting nongovernmental ganizations and private providers to deliver basic services to underserved groups(35)
Health Systems: principled integrated care 113 doctors and nurses make up only a small proportion of professional migrants, their loss weakens health systems. The internal movement of the workforce to urban areas is common to all countries. Within a region, there is also movement from poorer to richer countries, for example from Zambia to South Africa or from the United Republic of Tanzania to Botswana. The most controversial “brain drain” is international professional migration from poorer to wealthier countries (30). While the departure of doctors receives the most attention, it is the departure of nurses and other health professionals that can easily cripple a health system. Nurses are in high demand in developed countries, partly because of population ageing. Some efforts have been made to promote ethical practices in international recruitment, but results have yet to be assessed (31). Workforce mobility creates additional imbalances just when increased financial resources are beginning to flow to some developing countries. This requires better workforce planning in developed countries, attention to issues of pay and other rewards in developing countries, and improved management of the workforce in all countries. Paying more and paying differently Raising wages may increase the number of health workers and their productivity and may succeed in countries where health workers are paid less than comparable professions. It may be less successful, however, in countries where health sector wages are higher than those of comparable professions. Wages take the single largest share of health expenditure, so increases have to be carefully evaluated for their impact both on the availability and productivity of health workers and on aggregate budgets. The role of public sector unions in negotiating with governments for pay increases is an additional complexity. As well as raising salaries, other strategies to improve productivity include non-financial benefits such as housing, electricity and telephones, on-the-job training with professional supervision, and opportunities for rotation and promotion. In rural Senegal, providing nurses with motorcycles not only made it possible to increase immunization coverage but also improved their access to technical support and reduced their isolation (32). Both financial and non-financial incentives can also reduce geographical imbalances in the distribution of health workers. For example, in Indonesia, a bonus of as much as 100% of the normal salary attracted medical graduates from Jakarta to the outer islands (33). Recruitment and training of people from remote areas, who are committed to their region of origin, have also been proposed. Finally, nongovernmental organizations concerned with health and private providers are a large and increasing presence in most countries. Governments could consider partnerships in which the public sector provides financial support and the nongovernmental organizations manage and provide the direct services. Often, private health workers are available in places that the public sector finds difficult to reach. In such situations, establishing formal programmes either to contract private providers or to reimburse the services they provide may be the most pragmatic response. In the mid-1990s, the Government of Guatemala was obliged to expand health care services to unserved populations as part of the negotiated peace agreements that took place at the time. It contracted more than 100 nongovernmental organizations to provide basic health care services to some 3 million of the country’s citizens, predominantly indigenous and rural people, who previously had no access to services (34). Recently, Cambodia has successfully experimented with contracting nongovernmental organizations and private providers to deliver basic services to underserved groups (35)