Knowledge Brief Health, Nutrition and Population Global Practice 93388 THE ROLE OF THE PRIVATE SECTOR IN REPRODUCTIVE Reforming Remuneration and HR Practices HEALTH SERVICES IN Cambodia’s for BANGLADESH Health Professionals Ahmed Al-Sabir, Bushra Binte Alam, and Sameh El-Saharty November May 2014 2014 KEY MESSAGES: Cambodia has faced daunting challenges in rebuilding its health workforce following the Khmer Rouge genocide of 1975-79, during which about 90 percent of health professionals perished, and the period of civil war that then continued until the 1990s. Today, government salaries for medical workers remain low and most public sector health professionals depend on a combination incentive payments financed by government or development partners, income from providing health services outside their public sector jobs in the private sector, or by seeking non-medical second jobs. Although public health services should be relatively low cost or free, evidence suggests that many public sector health workers request gifts or payments. A variety of health financing and incentive schemes have been adopted over the years since the 1990s. With a view to improving service delivery in the health sector, the World Bank recently undertook a study 1 to inform policies on: the compensation of public health workers; the management, motivation and incentives for public health workers; how to manage the existence of dual practice; and key reforms to financial initiatives such as Health Equity Funds (HEFs) and Special Operating Agencies (SOAs), both of which have an important impact on health workers. The resulting findings are important in reforming Cambodia’s human resources for health (HRH) policies and providing solutions to enable Cambodia’s health sector to play its full role in helping Cambodian citizens to fulfill their potential . recommendations. The survey covered 1,168 health Overview professionals, based on a representative sample of the The supply, distribution, skills, and motivation of the total population of 5,404 health professionals in 19 Cambodia health workforce are key determinants of operational districts in nine provinces and five national health system performance. After primarily focusing on hospitals in Phnom Penh. Two primary questionnaires increasing the supply of public sector health workers, were used: (i) a Public Health Professional (HP) there is now a policy shift towards improving the Questionnaire covering compensation or incomes and distribution, skills, performance and quality of staff in both motivations and perceptions on HR tools among HPs the public The and of findings private health the two sectors. studies This suggest Policy that Note healers, traditional working suchinasthe Krupublic sector; and Khmer/witch (ii) ashops Facility doctors, Manager selling pills outlines the findings from a recent review of these Questionnaire targeting the head of each facility and and — issues traditional a survey (TBAs), birth attendants which included of overaccount for half of total rural health care providers, followed by private and 1,000 health covering a census plus questions on facilities and facility public workers — providers. drawing some Health utilization system and conclusions offeringindicates that 65 percent needs, of all as well as primary health motivation care visits were to the of staff. private sector, although 60 percent of hospitalizations took place in public facilities. Possessing an HEF card increases health seeking towards the public sector to 34 percent (up from 15 percent), but only 46 percent of the poor Pagehave 1 such cards. Half of women deliver their babies at home, and of those only 11 percent are attended by skilled medical personnel, while 88 percent are assisted by TBAs. Only 54 percent of private providers have formal training. Given the HNPGP Knowledge Brief • Key Findings • Various incentive schemes can double total Some of the key findings of the World Bank’s review are incomes, but the schemes are fragmented and provided below: not consistently linked to performance. • Total health worker income has increased; Incentive payments come in several forms: (i) dual practice income remains significant, but payments for health projects; (ii) user fees and has declined as a percentage of total income Heath Equity Funds (HEFs)1; service delivery since 2004. Since 2004, public health worker grants (SDGs) to Special Operating Agencies compensation has more than doubled on average (SOAs)2; and midwifery incentive payments. in nominal terms, including base salary and Several findings emerge: allowances, government incentives (financed by o Incentive payments double public health either the Government or development partners), worker income on average, but with high and dual practice earnings. Government variations depending on the incentives compensation (including incentives) as an available at a particular facility. average percentage of total income rose from o Staff are often unclear about the criteria one-third to about half, but dual practice remains for incentives, or perceive them to be the main income source for specialists/doctors unfair, or not based on their own (see Figure 1). performance. • Salaries of public sector health workers o Average incentives for doctors and remain low, with limited variation based on specialists are only slightly higher than skills or experience. The average base salary those for other staff, which means that including allowances for public HPs is only about incentives fail to remedy the compression US$100 per month, with doctors and specialists of public sector compensation for doctors earning only 50 percent more than the average, and specialists. making salaries highly compressed. Government o Delays in payment of incentives reduce incentives roughly double total government linkages between performance and compensation across most categories of staff. In rewards. contrast, average dual practice income for o Although incentives could be used to specialists is over US$800 per month, 2.5 times prioritize rural services, for example, most higher than total public sector earnings. are not currently designed to do so. • Half public sector health workers work in dual Figure 1. Specialists and doctors earn slightly higher practice, while about one-third have second government salary and incentives, but substantially higher non-medical jobs. Seventy percent of doctors dual practice earnings, compared with other skill report doing dual practice work, while primary classifications. nurses and midwives are more likely to have non- medical second jobs than dual practice. Dual practice incomes average US$50-US$350 a month, with some specialists/doctors reporting US$1,500 or more a month. Most health workers report that dual practice is becoming more difficult because of increased workloads and time- management conflicts in the public sector. • Satisfaction and accountability for performance appear to be highest at SOA health centers. These are higher than for SOA hospitals, with the worst levels found in at national hospitals, even though these have the most autonomy (as Public Administrative 1 Health Equity Funds (HEFs) pay user fees on behalf of the poor. They are financed by government and development partners, and usually operated by NGOs, and currently cover about one-third of the country geographically. 2 Special Operating Agencies (SOAs) are granted increased autonomy Source: HR Inc. Note: In this figure, dual practice earnings are averaged across all (particularly with respect to paying staff incentives) in exchange for health professionals, regardless of whether or not they participate in dual practice. greater accountability. Currently, 22 of Cambodia’s 76 health districts Subsequent figures show dual practice earnings only for those engaged in are SOAs, along with eight referral hospitals. SDGs currently are dual practice. financed by the Second Health Sector Support Program to provide performance-based financing to SOAs. Page 2 HNPGP Knowledge Brief • Enterprises). SOA health center staff earn more private sector; incentivize provision of priority and report working longer hours than staff in non- services; encourage staff to serve in rural or SOA health centers. remote areas; or reduce and better regulate dual • Median public sector compensation diverges practice. most from that of the private sector for 3. Different approaches will be needed to experienced doctors and specialists. Total address compensation and motivation for staff public income for entry-level public sector health at health centers as opposed to hospitals; for professionals is now on a par with the private nurses and midwives as opposed to sector. Experienced public sector nurses and specialists/doctors; and for staff in rural versus midwives earn about one-third of their total urban areas. Health workers in rural areas have income from dual practice, and their median total less access to user-fee revenue and dual-practice income is on par with the private sector. However, income, but their salaries and incentive schemes private sector earnings for experienced doctors fail to compensate them for these losses. This and specialists (10 years plus experience) are makes it harder to attract and retain staff in rural several times higher than public earnings. For areas. experienced doctors and specialists, when dual practice income is added to public sector income, Figure 2. Urban HWs earn more incentives and far more this puts their earnings on a par with experienced dual practice income than rural health workers, and private sector doctors and specialists. hospital workers earn more than health center workers • Most public health workers do not want to (average) lose their public sector jobs, but have unrealistic expectations of additional pay if they forgo dual practice. Health workers generally prefer to retain their public sector jobs due to better access to training, job security and pensions, plus opportunities for dual practice. But, leaving aside specialists and some doctors, most other health workers would expect total incentives several times higher than current dual practice earnings before they would consider leaving dual practice entirely. • Job satisfaction and other motivators are also important for health workers, including access to training, a supportive work environment, and adequate equipment. Staff and managers at SOAs rated their satisfaction and motivation higher than other health professionals. 4. Despite incentives, dual practice remains Conclusions widespread. Experience from other countries Several important conclusions emerge from the findings suggests that banning it would be difficult and outlined above, as follows: possibly counterproductive. Instead, dual practice 1. Public sector salaries remain inadequate needs to be better regulated and the negative relative to the private sector and dual practice effects mitigated by compensation reforms and earnings, and are highly compressed. As such, strengthened accountability and oversight. the Government’s policy in recent ye ars of 20 5. Salary increases or incentives alone are percent annual increases in all base salaries is inadequate for improving motivation and insufficient to redress this imbalance, especially performance, but need to be linked to increased for doctors and specialists, who can earn far more accountability. Performance management has in the private sector. been improving but the performance 2. Various incentive schemes are not equitably management and appraisal system (PMAS) distributed, adequately linked to performance, system could be further streamlined. sustainably financed, or guided by a clear policy 6. Increased autonomy for health facilities, while framework. This is likely to reduce the impact of promising, needs to be linked to stronger incentives on staff motivation and distribution. accountability. The current SOA and SDG Clarifying objectives would help to guide policy payment model appears to work better in health development to achieve specific goals, which centers than in hospitals. could be to: top up salaries to levels closer to the Page 3 HNPGP Knowledge Brief • 7. The current design of SDG grants works better for understood by staff. primary care than in hospitals, while payments 8. based on service outputs provided (HEFs) seem Strengthen policies for the use of non-financial to work better in hospitals. This is consistent with incentives in order to improve the motivation and global experience on provider payment distribution of staff. For example, this could include systems. priority access to training and promotions for those in rural areas. Figure 3. SOA staff receive more incentive income, but only slightly less dual practice income (average) Strengthen autonomy and accountability for public service providers. The SOA/SDG model seems to have improved accountability in health centers, but not in referral hospitals. National hospitals have the most autonomy, but also the greatest difficulty with HR management and performance accountability. • For SOAs and non-SOAs, improve vertical accountability, as well as independent performance monitoring, with a greater role for citizens and local governments. • Review PMAS for streamlining and increase effectiveness in management performance. • Strengthen oversight mechanisms for national hospitals (PAEs), including specific performance contracts. • Give greater flexibility to facility managers to influence staff deployment/assignment and performance management, with checks and balances. Policy Recommendations Formalize and regulate dual-practice working Establish a policy framework for payment of non- arrangements. A sanction system alone would be salary incentives. This should include a clear statement ineffective while wide public/private wage gaps persist. of objectives; transparent rules for the distribution of • For staff on full-time contracts, strengthen incentives (among facilities; within facilities; and among enforcement of public sector working hours, and categories of staff); and accountability and oversight establish guidelines for dual practice outside mechanisms. Establish appropriate maximum and working hours. minimum incentive allocations for various job categories. • Establish part-time contracts for specialist staff, with clear criteria for hours worked, and Consolidate current incentive schemes. Two questions performance standards and ethics (for example, should be considered: How to pay health facilities for no “poaching� of patients). services (outputs and quality); and how to pay health • Phase out dual practice for hospital managers in workers within those facilities? exchange for higher performance-based pay. • Break the linkage between revenue-earning • Establish premiums for highly skilled staff and opportunities of health facilities and their ability to managers who eschew dual practice. finance salaries and incentives. • For referral and national hospitals, shift financing Strengthen systems and capacity for management towards output-based payment systems, through and professional development. a combination of HEFs, Social Health Insurance, • Provide training and mentoring of managers at all and performance-based transfers. levels, including in HR and staff performance • Establish a consolidated payment system for management. health centers, integrating output-based elements • Build closer links through training for both public of HEFs and midwifery incentives with quality- and private sector health professionals. based per capita payments (similar to SDGs). • Strengthen links between the HR and personnel • Establish guidelines for allocating incentive management system, and the performance income to staff within facilities and introduce management information system. transparent information systems to monitor/report payments to managers and staff. Implement civil service pay reform. This needs to be • Ensure criteria for incentives are clearly done to ensure effective management and oversight of Page 4 HNPGP Knowledge Brief service delivery in the health system. revenue to be pooled and used for performance- • Implement a public sector compensation system, based monitoring. with competitive remuneration for health sector • Look into whether service delivery medical civil service managers, regulators and “back - professionals and facility managers should office� staff. continue as civil servants or shift to fixed-term • Look into transitional options for the sector, for contracts. example allowing a small percentage of incentive The Health, Nutrition and Population Knowledge Briefs of the World Bank are quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, please contact Miguel Sanjoaquin, Health Economist (msanjoaquinpolo@worldbank.org) Page 5