Public Health Minister Pradit Sintawanarong may have good intentions in introducing a pay-for-performance system to administer our public health workforce _ doctors, dentists, nurses and others.
I am only guessing at his intentions here because truth be told, I have never been informed of the details of what exactly it is he is trying to achieve.
And that is a big part of the problem. That is probably the reason why the minister finds himself in a rather messy situation with hundreds of doctors shedding their scrubs and surgical masks for wide-rimmed hats so they can go out in the sun and protest against him.
Even though the minister has signed the order into force, effective since April 1, resistance remains high. Doctors at rural hospitals who form the main opposition group do not seem eager to implement the order. Instead they are planning their next move against the minister.
The use of a pay-for-performance (P4P) scheme, while still debatable as to whether it will be able to motivate medical personnel to produce the required results, is nothing new.
Studies are numerous, describing what could lead to such a scheme's success or failure. They talk about the circumstances in which a scheme should be applied, or not. Immature personnel, weak managerial skills or weak capacity to design and monitor performance and incentives, and limited competition are all reasons not to go ahead.
They also talk about the conditions that could lead to success, such as a post-conflict setting in which NGOs are strong while the government is weak.
Almost every study, however, points to the need for people who will have to be part of the scheme to be involved in its design.
Doctors, dentists, nurses and other medical personnel whose work will have to be assessed by these sets of criteria and key performance indices must have a say from the start on what the P4P scheme is supposed to achieve and how best to design incentives to get there.
The medical profession is difficult to standardise. Like many people in other professions, doctors, nurses or other medical personnel are not motivated by money alone. There are many factors at play that make them do what they do, or which could encourage them to do it better or more efficiently.
Those factors do not necessarily include having half of their existing hardship allowance cut with the other half - the performance-related part -_ dictated by something they are not sure will reflect their values or will justly judge how they perform in their tasks. Indeed, I am confused myself why the Public Health Minister needed to fuse the hardship allowance issue with P4P.
The hardship allowance was there to tackle another issue, which is a lack of doctors or specialists in remote areas where difficulties are high and opportunities to freelance are low.
If the minister thinks some areas are no longer qualified as hardship postings - Bang Bua Thong, for instance - he could reclassify the whole hardship postings definition. But why tie it to the other issue of P4P, which I assume is there for a different purpose of increasing efficiency in medical personnel?
Again, I am only assuming that is the minister's purpose.
While I do not oppose the health minister's idea of introducing the P4P to the public health workforce - it's inevitable that we need to have standardisation and accountability in the workforce as we move into the future - I believe the good doctor could have administered this project much more prudently.
From the start, Dr Pradit will have to state his purpose clearly. Is this P4P designed to increase efficiency among health service providers, to cut hardship allowances or improve health services for the poor?
After that, he will have to design the programme to achieve the desired results.
As for doctors protesting against the scheme, I do share their concerns and I have sympathy for their cause. Still, I believe they can't reject the idea of P4P just because it's being badly carried out.
They can't keep saying that they are doing their job as a "sacrifice" for the country or the greater good.
Doctors will always command respect, even reverence, because of their role in saving lives. But more and more, people will demand that they are accountable to their profession. A certain type of professional standard agreed upon by everyone must be enforced, if not now then at some point in the future.
It's best for them to start doing it now and offer their vision of what it should be like, instead of just voicing their disapproval.
Atiya Achakulwisut is Deputy Editor, Bangkok Post.
About the author
- Writer: Atiya Achakulwisut
Position: Deputy Editor (Day)