Physician salaries: one ingredient in the cake of retention

By Kate Tulenko

With the global migration of health workers increasing and population growth outstripping the training of new health workers in more and more countries, there is increasing emphasis on finding effective ways to retain health workers in country. In an effort to add light to this issue Edward Okeke from the Rand Corporation published the paper “Do Higher Salaries Lower Physician Migration?” in Health Policy and Planning. The research takes advantage of a natural experiment starting in 1999, when the Government of Ghana raised physician wages in the public sector by 75%, to 150%. Okeke looks specifically at the trend in migration of physicians from Ghana, compared to other African countries, in the period following 1999, and notes a decrease in Ghanaian physician outflows compared to other countries that did not significantly increase physician wages during the same period.

Yes, wages matter, but a policy advisor reading Okeke’s paper would be remiss to recommend only increasing physician wages. The World Health Organization Guidelines on Remote and Rural Retention recommends that incentives be delivered in multi-dimensional packages rather than single incentives. The power of multi-incentive packages has also been affirmed in numerous Discrete Choice Experiments (DCE), systemic surveys of workers to determine what financial and non-financial incentives will retain them in certain positions. These packages, which include improved housing, access to low interest loans, access to further education and increased salaries, turn out to be more cost effective than increased salaries alone. Our DCE results from Uganda and Laos reveal that health worker retention can be increased by investing in the very inputs that will help them do their jobs better: adequate supplies of medicines and equipment and supportive supervision.

Significantly increasing wages also brings concerns about sustainability: can governments afford it over the long term? And in countries where worker salaries already constitute up to 70% of Ministry of Health budgets, increasing wages might translate to lower investment in other critical health sector inputs, such as health facilities, medical consumables (drugs, gloves, bandages, diagnostic test and equipment, etc.) or other vital members of the healthcare team (nurses, midwives, community health workers). While a clinic without a doctor may be of little use, a doctor without the other necessary inputs is also of little use. In addition, if countries double the wages of physicians they run the risk that other health sector workers will demand increased wages. Or the wage inflation may extend to all government workers beyond the health sector into education, the police, and other public sector workers.

Retention packages should not focus solely on retention within country. They need to be fine-tuned so that they attract and retain health workers to medically underserved communities in country, especially rural areas, where they are most needed—not just the capital city.

Another consideration is: what was the cost of increasing the wages?  How many other physicians or mid-level providers such a midwives or clinical officers could have been trained using those funds?

A final message to the Ministry of Health policy advisor working on assuring staffing in underserved communities is the need for better data. This, indeed, was one of the main outcomes of the dialogue during the Third Global Forum on Human Resources for Health which took place in Recife, Brazil, this month and one of the main messages in Global Health Workforce Alliance’s publication “A Universal Truth: No Health Without a Workforce“. Most countries have little data on how many of what type of health worker they have or where they work. Countries can start to take control of their labour markets and achieve huge progress in making better use of their existing health workers by the simple first step of knowing who their health workers are and where they work.

Kate Tulenko is Director of CapacityPlus and Senior Director for Health Systems Innovation at IntraHealth International


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