In a spectacular example of how self-interest rules so much health debate, rural doctors are arguing for yet more financial incentives to work in the bush.

The only problem is that they are citing a new international report to back their latest argument – although if you actually read the report, it is far from suggesting that countries like Australia should spend more money on rural doctors.

The Rural Doctors Association of Australia statement from earlier this week said:

The urgent need for a Rural Rescue Package to entice more doctors to rural Australia has been underlined by new international guidelines which show that financial incentives are critical in ensuring the effective recruitment and retention of health workers across the world.

The document, Guidelines on Incentives for Health Professionals, was commissioned by the Global Health Workforce Alliance (GHWA)—a body affiliated with the World Health Organisation—as part of its work to identify and implement solutions to the global health workforce crisis.

It might be a touch harsh coming from an ex-President, but I did wonder if the organisation had even read the GHWA report before attaching to it their standard “Rural Rescue Package” mantra.

For a start, Australia is clearly listed as being one of the nations without critical workforce shortage, which is not surprising given that the report’s terms of reference require special attention to developing countries and the report focuses on sub-Saharan Africa, South East Asia, and Latin America.

Even more amusingly, the report calls into question a focus on doctors at all, quoting the benefits of community-based and mid-level health workers in particular:

The World Bank’s analysis shows that if there were a greater concentration on community health workers, the number of additional staff that could be employed for the same funding under the current trends scenario might increase – from about 650,000 to more than 900,00. In contrast, if there were a greater concentration of doctors, the additional number of health workers who could be employed for the same funds decreases to less than 400,000.

It is also apparent that the focus of recommendations in the report for increasing workforce, including that for poor and rural areas, relied on locally-based education strategies, including commencing training within school, and teamed with on-going local and international mentorships — rather than financial incentives. There was even mention of return of service obligations.

The best I could find in the way of “overwhelming” evidence of the benefit of rural incentive payments in the 123 pages were two comments:

Given that training new cadres takes time, short-term or temporary solutions to ease the crisis should not be overlooked. Some examples include the use of the diaspora and expatriates, bilateral agreements to provide health workers and redistribution of existing workers via incentives for rural service.

followed by:

…address attrition and retention in the workforce, including remuneration for all, good working conditions, career development and, potentially, additional incentive packages for rural service.

Meanwhile, the summary clearly stated:

Community health workers represent the quickest way to increase access to many essential health interventions in rural and urban areas, and to ensure that services reach poor communities.

All of which raises a few very interesting question for health planners: Are we putting too much money into incentives for doctors? And should we instead be investing much more broadly in developing a rural health workforce?

In fact, just the sort of questions a medico-political organisation is unlikely to want raised.

Peter Fray

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