Assess the costs of implementing the evidence-based policy intervention

Before implementing any policy or strategy, it is important to gather information about the costs of evidence-based policy recommendations and their fiscal context (HWAI 2008). In addition to other factors, the cost of implementing a given policy solution and the ability to sustain the costs over time may influence whether decision-makers view it as politically feasible, and can shape their willingness to adopt it. Ditlopo et al. (2013) found this to be a challenge in the case of the South African nursing retention incentive strategy. Competing national priorities (such as roads, infrastructure, education, or energy) may constrain the fiscal and political space. Depending on the type of policy, strategies should be presented with high, moderate, and low investment options so that stakeholders can make choices based on the budget that is available currently, and likely to be available in the foreseeable future for strategies that require continuous support or long-term implementation (Health Policy Initiative 2010). Conducting a cost-benefit analysis using discrete choice experiment, costing, health outcomes, and HRH data can show the full value of recruitment and retention policies by identifying the incentive packages “that are more likely to result in lower net costs (relative to the initial direct costs) or even generate a net benefit from the societal perspective, given the indirect health benefits conferred in each package,” as was done in Lao People’s Democratic Republic (Keuffel et al. 2013, 990). Cost information is most useful when it is available concurrently or soon after presenting the proposed strategy to avoid any lag that could stall decision-making and action (Bhuyan, Jorgensen, and Sharma 2010).


In Uganda, after the discrete choice experiment survey identified which incentive packages would be most likely to motivate health workers to work in rural areas, a technical team used iHRIS Retain, open source retention intervention costing software, to cost many different scenarios of retention incentive strategies for each cadre and estimate their budget implications. The incentive package most-preferred by health workers represented a comprehensive approach to improving the work environment, including interventions to increase salaries, improve facility infrastructure and management, and provide support for continuing education, but necessitated a substantial financial investment. Another package provided an optimal preference by health workers but moderate financial cost as the facility infrastructure improvements were limited to primary care facilities. The minimum investment scenario of incentives appealed to the fewest health workers, as it did not include improvements to facility infrastructure.

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