Evidence on the impact of salary supplementation schemes on performance of health workers

Helpdesk Query:

What is the evidence on the impact of salary supplementation schemes on the performance of health workers?

Summary:

This helpdesk report explores the evidence available on the impact of salary supplementation schemes on the performance, recruitment and retention of health workers. Salary supplementation can be defined as monetary payments or in-kind benefits paid to staff above the standard compensation for their position. There are two key types of salary supplementation schemes: those aiming to improve the performance of existing staff, and those that are primarily concerned with attracting and retaining staff in either roles or regions which prove challenging to fill.

The use of salary supplementation, particularly performance-based supplementation, is however a contentious topic, with studies and reports in favour of it offset by those suggesting that in many ways it is ineffective or may do more harm than good for reasons including system gaming, unbalancing priorities and corruption. Overall, it seems that though results based financing can be beneficial in certain cases, it must be implemented very carefully, with extensive consideration of the wider system and motivations, and with very close monitoring to minimise system gaming and other unintended consequences. Salary supplementation for attracting and retaining health workers is far less contentious, with a broad consensus that it is effective in a wide range of circumstances, though this approach too faces challenges, primarily in terms of ensuring sustainability of results and potential neglect of non-financial incentives. A clear exit strategy is also important, as perhaps the greatest issue with salary supplementation is the difficulty with phasing out support.

This report separates the evidence into five key categories: evidence broadly in support of performance-based financing; evidence broadly against performance-based financing; evidence broadly in support of salary supplementation for the attraction and retention of health workers; evidence broadly against salary supplementation for the attraction and retention of health workers; and other useful resources.

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