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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 November 10; 335(7627): 954.
PMCID: PMC2071999
Health in an Unequal World

What about the needs of health workers in developing countries?

Neil Pakenham-Walsh, coordinator, Healthcare Information For All by 2015

In their randomised trial showing reduced in-hospital mortality after improved management of children under 5 years with malaria, Biai et al concede that “we cannot distinguish between the effect of supervising the implementation of the guidelines and the effect of the financial incentive in reducing mortality.”1 But this crucial point was lost in the abstract—and in others' interpretations:

  • • The box summarising what the study adds—“In poor countries, small financial incentives can contribute to a dramatic decrease in in-hospital mortality”1
  • • The latest headlines on on 2 November 2007—“Financial incentives may hold key to cutting child malaria deaths”
  • • Editor's choice—“Mortality from malaria on the children's ward, once people's poverty was tackled head on, was just 5% in the intervention group and 10% for controls”2
  • • The accompanying editorial—“The extra pay was enough to enable staff to work efficiently.”3

There was no mention of how the unequal hospital environment created by the study may itself have contributed to the results. It would have been useful to hear from the nurses and doctors themselves. How did it feel to be in the control group, to receive no extra money, and to have to continue moonlighting to pay for food and rent, while colleagues (working in a similar children's ward in the same building) enjoyed a monthly bonus ($50 and $160 a month for nurses and doctors respectively)? The bonus is described by authors and commentators as small, but small is relative. We are not told the basic salaries of nurses and doctors in the study, but in Guinea-Bissau, where this study took place, a chief nurse with 18 years' service reports that she earns less than $100 a month.4

For further discussion on the needs of health workers in developing countries, join HIFA2015 (Healthcare Information For All by 2015) and CHILD2015 global email discussion groups (1000 plus members from 95 countries worldwide). Send your name, affiliation, and brief description of professional interests to and


Competing interests: None declared.


1. Biai S, Rodrigues A, Gomes M, Ribeiro I, Sodemann M, Alves F, et al. Reduced in-hospital mortality after improved management of children under 5 years admitted to hospital with malaria: randomised trial. BMJ 2007;335:862-5. (27 October.) (free access) [PMC free article] [PubMed]
2. Groves T. Make health inequality history. Editor's choice. BMJ 2007;335. (27 October.) doi:10.1136/bmj.39377.555324.47
3. Tumwine J. Equitable access to health care. BMJ 2007;335:833-4. (27 October.) [PMC free article] [PubMed]
4. Guinea-Bissau: Health service far from well.

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