Health Systems: principled integrated care doctors and nurses make up only a small proportion of professional migrants, their loss weak ns health systems. The internal movement of the workforce to urban areas is common to all countries within a region, there is also movement from poorer to richer countries, for example from Zambia to South Africa or from the United Republic of Tanzania to Botswana. The most controversial brain drain"is international professional migration from poorer to wealthier countries(30) While the departure of doctors receives the most attention, it is the departure of nurses and other health professionals that can easily cripple a health system. Nurses are in high demand in developed countries, partly because of population ageing. Some efforts have been made to promote ethical practices in international recruitment, but results have yet to be assessed (31) Workforce mobility creates additional imbalances just when increased financial resources are beginning to flow to some developing countries. This requires better workforce planning developed countries, attention to issues of pay and other rewards in developing countries, and improved management of the workforce in all countries Paying more and paying differently Raising wages may increase the number of health workers and their productivity and may succeed in countries where health workers are paid less than comparable professions. It may be less successful, however, in countries where health sector wages are higher than those of comparable professions. Wages take the single largest share of health expenditure, so increases have to be carefully evaluated for their impact both on the availability and productivity of health workers and on aggregate budgets. The role of public sector unions in negotiating with governments for pay increases is an additional complexity As well as raising salaries, other strategies to improve productivity include non-financial ben efits such as housing, electricity and telephones, on-the-job training with professional super- vision,and opportunities for rotation and promotion. In rural Senegal, providing nurses with motorcycles not only made it possible to increase immunization coverage but also im- proved their access to technical support and reduced their isolation(32) Both financial and non-financial incentives can also reduce geographical imbalances in the distribution of health workers. For example, in Indonesia, a bonus of as much as 100% of the normal salary attracted medical graduates from Jakarta to the outer islands(33). Recruit ment and training of people from remote areas, who are committed to their region of origin have also been proposed. Finally, nongovernmental organizations concerned with health and private providers are a large and increasing presence in most countries Governments could consider partnerships in which the public sector provides financial support and the nongovernmental organiza tions manage and provide the direct services. Often, private health workers are available in places that the public sector finds difficult to reach. In such situations, establishing formal programmes either to contract private providers or to reimburse the services they provide may be the most pragmatic response. In the mid-1990s, the Government of Guatemala was obliged to expand health care services to unserved populations as part of the negotiated peace agreements that took place at the time It contracted more than 100 nongovernmental or ganizations to provide basic health care services to some 3 million of the country's citizens, predominantly indigenous and rural people, who previously had no access to services(34) Recently, Cambodia has successfully experimented with contracting nongovernmental ganizations and private providers to deliver basic services to underserved groups(35).Health Systems: principled integrated care 113 doctors and nurses make up only a small proportion of professional migrants, their loss weak￾ens health systems. The internal movement of the workforce to urban areas is common to all countries. Within a region, there is also movement from poorer to richer countries, for example from Zambia to South Africa or from the United Republic of Tanzania to Botswana. The most controversial “brain drain” is international professional migration from poorer to wealthier countries (30). While the departure of doctors receives the most attention, it is the departure of nurses and other health professionals that can easily cripple a health system. Nurses are in high demand in developed countries, partly because of population ageing. Some efforts have been made to promote ethical practices in international recruitment, but results have yet to be assessed (31). Workforce mobility creates additional imbalances just when increased financial resources are beginning to flow to some developing countries. This requires better workforce planning in developed countries, attention to issues of pay and other rewards in developing countries, and improved management of the workforce in all countries. Paying more and paying differently Raising wages may increase the number of health workers and their productivity and may succeed in countries where health workers are paid less than comparable professions. It may be less successful, however, in countries where health sector wages are higher than those of comparable professions. Wages take the single largest share of health expenditure, so increases have to be carefully evaluated for their impact both on the availability and productivity of health workers and on aggregate budgets. The role of public sector unions in negotiating with governments for pay increases is an additional complexity. As well as raising salaries, other strategies to improve productivity include non-financial ben￾efits such as housing, electricity and telephones, on-the-job training with professional super￾vision, and opportunities for rotation and promotion. In rural Senegal, providing nurses with motorcycles not only made it possible to increase immunization coverage but also im￾proved their access to technical support and reduced their isolation (32). Both financial and non-financial incentives can also reduce geographical imbalances in the distribution of health workers. For example, in Indonesia, a bonus of as much as 100% of the normal salary attracted medical graduates from Jakarta to the outer islands (33). Recruit￾ment and training of people from remote areas, who are committed to their region of origin, have also been proposed. Finally, nongovernmental organizations concerned with health and private providers are a large and increasing presence in most countries. Governments could consider partnerships in which the public sector provides financial support and the nongovernmental organiza￾tions manage and provide the direct services. Often, private health workers are available in places that the public sector finds difficult to reach. In such situations, establishing formal programmes either to contract private providers or to reimburse the services they provide may be the most pragmatic response. In the mid-1990s, the Government of Guatemala was obliged to expand health care services to unserved populations as part of the negotiated peace agreements that took place at the time. It contracted more than 100 nongovernmental or￾ganizations to provide basic health care services to some 3 million of the country’s citizens, predominantly indigenous and rural people, who previously had no access to services (34). Recently, Cambodia has successfully experimented with contracting nongovernmental or￾ganizations and private providers to deliver basic services to underserved groups (35)