and quality of health service delivery. How public sector health workers are recruited, deployed, monitored, and perform is critical to health care delivery performance and governed by underlying health system incentives and lines of accountability. Hard evidence on these topics is scarce; most of the available measures of performance are negative and include indicators such as absenteeism and reliance on bribery or personal contacts to obtain jobs and promotions. This section outlines the main governance issues and potential performance indicators, and examines existing evidence and possible solutions to the persistent challenges facing human resource management in health.

# **Designing recruitment and assignment to improve performance**

Civil service regulations and recruitment systems are intended to ensure a professional, politically neutral workforce with appointment and promotion based on transparent civil service regulations and pay scales. With those advantages can come disincentives for performance including compression of pay differentials that make rewards minimal, promotion based on seniority rather than performance, lack of mechanisms to monitor effort, and limited or no freedom of managers to reward and discipline staff. Civil service reforms can address some of these limitations but pose political and operational difficulties.

Physician and nurse performance can be enhanced through (1) policies that promote the recruitment, hiring, transfer, and assignment of adequately trained staff; (2) appropriate incentives; and (3) effective accountability mechanisms. While it is relatively simple to outline the processes, implementation is complex. Without consideration of these components human resource management becomes susceptible to some combination of political manipulation, mismanagement, nepotism/favoritism, and fraud, which can compromise performance.

To ensure hiring of qualified health workers and their continued technical effectiveness typically requires that physicians and nurses obtain their medical or nursing degrees from accredited institutions. Also important are licensing exams, which assure that upon graduation a physician or nurse “has successfully completed an appropriate sequence of medical education...and has demonstrated competence through successful completion of an examination or other certification demonstrating qualification for licensure”.<sup>14</sup> Requirements for continuing education and re-licensing may also exist, and in many cases also complaint mechanisms for reporting medical malpractice. Often such quality safeguards are absent in developing and transition countries; medical and nursing school accreditation is rare, licensing absent, and continuing education unavailable or only sporadically so, all of which make managing human resource for performance a serious challenge.

Armenia, for instance, has licensing procedures to ensure that physicians and nurses are adequately qualified and possess legitimate qualifications but health workers reported that a license could easily be obtained through bribery or contacts (Kurkchiyan 1999). Complaint mechanisms when they exist are only effective if patients actually make complaints and these are followed up by providers. Household survey data from

> 14 See the American Medical Association website at http://www.ama-assn.org/aps/physcred.html#license.

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