# _Providing opportunities for career development and training_

Availability of training and further education opportunities can create incentives for raising health worker performance, and ensures up-to-date technical skills. At the Children’s Hospital in Georgia, physician performance rewards in the form of opportunities to attend training and seminars, coupled with other rewards: preferred hours of work, preferred leave, and publicly-awarded recognition, led to improved physician performance (see Table 11 for more information). Data on posting locations chosen by recent medical graduates in Indonesia before and after a major change in incentives in the form of specialist training for those serving in remote areas, shows that physicians are more willing to serve in remote areas if specialist training that allows them to keep current is offered (Chomitz et al. 1998). However, such a solution may not be cost effective if the skills attained are not relevant to neither current nor future professional requirements.

# _Using community-based monitoring to improve health service delivery_

Community monitoring of health service providers to improve performance is appealing but there is little evidence on its effectiveness, and what exists is mixed at best. A randomized trial from Uganda suggests that as community-based monitoring of providers expanded, health service delivery improved. Communities started monitoring health facilities in nine districts in 2004. “Community contracts” between communities and providers were drawn up that defined the requirements for service improvement and methods of community monitoring. One year after the start of the monitoring program, there were notable increases in utilization, higher infant birth weights, and less underfive deaths in the treatment communities. The findings suggest that the improvements were the result of staff increasing their work effort as captured by lower absentee rates, shorter waiting times, and improved examination procedures (Björkman and Svensson 2007).

In Bolivia, corruption in local health service provision was lower where local oversight groups were active “suggesting that bottom-up accountability can be effective in keeping corruption in check” (Gatti, Gray-Molina and Klugman 2002: 1081). By contrast, in Jigawa state in Nigeria, hospital management committees meant to oversee and advise hospital managers rarely met, were unclear on their responsibilities, and had little involvement with strategic planning, targeting or budget control (World Bank 2005). Even more serious, in Uganda in ten public facilities with community monitoring through representatives on the Health Unit Management Committee (HUMC), the average leakage rate for drugs ranged from 40 to 94 percent and high demand drugs were unavailable to patients because health workers and HUMC members, the latter meant to provide local oversight, expropriated them (McPake et al. 1999).

A detailed case study from rural Africa provides further evidence on the difficulties associated with effective community monitoring. In the study corruption increased as village representatives held meetings with district officials in charge of allocating project funding to agree on how much to “pay” to get a particular project (Ensminger 2007). Once the project was allocated to the village the community selected three leaders and a committee trained in accounting and community driven-development. The leaders were then given access to the fundsand despite strict regulations on their use, 39