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Designing financial-incentive programmes for return of medical service in underserved areas: seven management functions

机译：为服务不足地区的医疗服务设计财务激励计划：七个管理职能

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In many countries worldwide, health worker shortages are one of the main constraints in achieving population health goals. Financial-incentive programmes for return of service, whereby participants receive payments in return for a commitment to practise for a period of time in a medically underserved area, can alleviate local and regional health worker shortages through a number of mechanisms. First, they can redirect the flow of those health workers who would have been educated without financial incentives from well-served to underserved areas. Second, they can add health workers to the pool of workers who would have been educated without financial incentives and place them in underserved areas. Third, financial-incentive programmes may improve the retention in underserved areas of those health workers who participate in a programme, but who would have worked in an underserved area without any financial incentives. Fourth, the programmes may increase the retention of all health workers in underserved areas by reducing the strength of some of the reasons why health workers leave such areas, including social isolation, lack of contact with colleagues, lack of support from medical specialists and heavy workload. We draw on studies of financial-incentive programmes and other initiatives with similar objectives to discuss seven management functions that are essential for the long-term success of financial-incentive programmes: financing (programmes may benefit from innovative donor financing schemes, such as endowment funds, international financing facilities or compensation payments); promotion (programmes should use tested communication channels in order to reach secondary school graduates and health workers); selection (programmes may use selection criteria to ensure programme success and to achieve supplementary policy goals); placement (programmes should match participants to areas in order to maximize participant satisfaction and retention); support (programmes should prepare participants for the time in an underserved area, stay in close contact with participants throughout the different phases of enrolment and help participants by assigning them mentors, establishing peer support systems or financing education courses relevant to work in underserved areas); enforcement (programmes may use community-based monitoring or outsource enforcement to existing institutions); and evaluation (in order to broaden the evidence on the effectiveness of financial incentives in increasing the health workforce in underserved areas, programmes in developing countries should evaluate their performance; in order to improve the strength of the evidence on the effectiveness of financial incentives, controlled experiments should be conducted where feasible). In comparison to other interventions to increase the supply of health workers to medically underserved areas, financial-incentive programmes have advantages – unlike initiatives using non-financial incentives, they establish legally enforceable commitments to work in underserved areas and, unlike compulsory service policies, they will not be opposed by health workers – as well as disadvantages – unlike initiatives using non-financial incentives, they may not improve the working and living conditions in underserved areas (which are important determinants of health workers' long-term retention) and, unlike compulsory service policies, they cannot guarantee that they will supply health workers to underserved areas who would not have worked in such areas without financial incentives. Financial incentives, non-financial incentives, and compulsory service are not mutually exclusive and may positively affect each other's performance.
机译：在世界许多国家，卫生工作者短缺是实现人口卫生目标的主要限制之一。服务返还的财务激励计划，使参与者获得报酬以换取对在医疗服务不足地区的一段时间执业的承诺，可以通过多种机制缓解本地和区域卫生工作者的短缺。首先，他们可以将那些本来没有财政刺激就受过教育的医务人员从服务良好的地区转移到服务不足的地区。其次，他们可以将卫生工作者增加到本来没有经济诱因的情况下接受教育的工作者中，并将他们安置在服务不足的地区。第三，财政激励计划可以改善那些参加该计划但在没有任何经济诱因的情况下原本会在服务不足地区工作的卫生工作者的服务不足地区。第四，该计划可能会通过减少某些原因（包括社会隔离，与同事缺乏联系，缺乏医疗专家的支持以及繁重的工作量）来减少某些医疗人员离开此类地区的原因，从而增加所有医疗人员在服务欠缺地区的保留率。我们基于对财务激励计划和其他具有类似目标的计划的研究，讨论了对财务激励计划的长期成功至关重要的七个管理职能：筹资（计划可能会受益于创新的捐助者筹资计划，例如捐赠基金，国际融资工具或赔偿金）;促进（方案应使用经过测试的交流渠道，以接触中学毕业生和卫生工作者）;选择（计划可以使用选择标准来确保计划成功并实现补充政策目标）;安置（计划应使参加者与地区相匹配，以最大程度地提高参加者的满意度和忠诚度）;支持（计划应为参加者在服务不足地区的时间做好准备，在入学的不同阶段与参与者保持密切联系，并通过指派导师，建立同伴支持系统或为与服务不足地区的工作相关的教育课程提供资助来帮助参与者）;执法（计划可以使用基于社区的监视或将执法外包给现有机构）;与评估（为了扩大关于经济激励措施在服务不足地区增加卫生人力的有效性的证据，发展中国家的计划应对其绩效进行评估;为了增强关于经济激励措施的证据的可控性实验应在可行的情况下进行）。与其他增加医疗服务不足地区的卫生工作者供应的干预措施相比，财务激励计划具有优势–与使用非财务激励措施不同，它们制定了在法律上可强制执行的承诺，以在服务不足地区开展工作，并且与强制性服务政策不同，它们不会受到卫生工作者的反对以及不利因素的影响-与采用非财务激励措施的举措不同，它们可能不会改善服务不足地区的工作和生活条件（这是卫生工作者长期留任的重要决定因素），并且与强制性服务政策，他们不能保证将医疗人员提供给服务不足的地区，这些地区如果没有经济激励措施就不会在这些地区工作。财务激励，非财务激励和义务服务不是相互排斥的，它们可能对彼此的绩效产生积极影响。

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