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Increasing Access to Health Workers in Remote and Rural Areas Through Improved Retention: Global Policy Recommendations. Geneva: World Health Organization; 2010.

Cover of Increasing Access to Health Workers in Remote and Rural Areas Through Improved Retention

Increasing Access to Health Workers in Remote and Rural Areas Through Improved Retention: Global Policy Recommendations.

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1Introduction

1.1. Rationale

Policy-makers in all countries, regardless of their level of economic development, struggle to achieve health equity and to meet the health needs of their populations, especially vulnerable and disadvantaged groups. One of their most complex challenges is ensuring people living in rural and remote locations have access to trained health workers. Skilled and motivated health workers in sufficient numbers at the right place and at the right time are critical to deliver effective health services and improve health outcomes. Insufficient numbers and types of qualified health workers in remote and rural areas impedes access to health-care services for a significant percentage of the population, slows progress towards attaining the Millennium Development Goals and challenges the aspirations of achieving health for all.

This is a global problem that affects almost all countries. Approximately one half of the global population lives in rural areas, but these areas are served by only 38% of the total nursing workforce and by less than a quarter of the total physician workforce (see Figure 1.1). The situation is especially dire in 57 countries where a critical shortage of trained health workers means an estimated one billion people have no access to essential health-care services (1). In Bangladesh, for example, 30% of nurses are located in four metropolitan districts where only 15% of the population lives (2). In South Africa, 46% of the population lives in rural areas, but only 12% of doctors and 19% of nurses are working there (3). To compound the problem, in some francophone sub-Saharan African countries, like Côte d'Ivoire, the Democratic Republic of the Congo and Mali, the overproduction of health workers relative to the capacity for absorption has led to medical unemployment in urban areas and shortages in rural areas (4).

Figure 1. Rural/urban worldwide distribution of physicians and nurses.

Figure 1

Rural/urban worldwide distribution of physicians and nurses. * Source: (18) ** Source: (1)

Even high-income countries have shortages of health workers in remote and rural areas. In the United States of America (USA), 9% of registered physicians practise in rural areas where 20% of the population lives (5). France has large inequalities in the density of general practitioners, with higher densities in the south and the capital compared with the centre and north of the country (6). And in Canada, only 9.3% of physicians work in remote and rural areas where 24% of the population lives (7).

Every government influences the health labour market through regulation, financing and information. An entirely free labour market will never lead to a well-distributed health workforce because many people are drawn to urban centres or in some cases to other countries.

An abundance of evidence and experience shows that political commitment and policy interventions are central to more equitable health workforce distribution. In countries as diverse as China, Cuba and Thailand, a variety of long-standing commitments towards the education, training and specific support of rural health workers have led to improvements in the population's access to committed health workers in these areas (8-10).

However, no country has completely solved these challenges; hence several recent international events have highlighted the importance of improving health worker retention and called for more effective policy interventions (see Box 1).

Box Icon

Box 1

International calls to action. The World Health Assembly resolutions on migration in 2004 and rapid scaling up of health workers in 2006 both requested Member States put in place mechanisms to address the retention of health workers. In March 2008, the (more...)

1.2. Objective

The World Health Organization (WHO) responded to calls to action from global leaders, civil society and Member States by convening a group of experts to examine existing knowledge and evidence and to provide up-to-date, practical guidance to policy-makers on how to design, implement and evaluate strategies to attract and retain health workers in rural and remote areas. In doing so, these recommendations support countries in their efforts to improve health outcomes by strengthening the capacity of health systems to provide quality health care that is accessible, responsive, effective, efficient and equitable.

1.3. Target audience

This report emphasizes that sustained political, institutional and financial commitments are needed, as is the involvement of many different stakeholders. As such, this report is aimed at government leaders and national policy-makers across several sectors including health, finance, education, labour and public service. Stakeholders include health system managers, human resource managers, heads of education and training institutions, employers of health workers, professional associations representing different cadres of health workers, civil society, nongovernmental organizations and remote and rural communities.

1.4. Scope

This is the first time that global recommendations have been published on this important issue. This report builds on work that has already been done in human resources for health, including the Joint Learning Initiative Report (11), the World Health Report 2006 (1), and the report of the Task Force on Scaling Up Education and Training of Health Workers (12). It draws on relevant methods and tools, including the HRH Action Framework (13) and the Handbook on Monitoring and Evaluation of Human Resources for Health (14).

The evidence-based recommendations relate to the movements of health workers within the boundaries of a country, and complement the current work of WHO on the Global Code of Practice on the International Recruitment of Health Personnel (see Annex 3), which aims to address the challenges of international movements of health workers (15).

The recommendations focus solely on strategies to increase the availability of motivated and skilled health workers in remote and rural areas through improved attraction, recruitment and retention of health workers in these areas. They become relevant once a country has assessed the health needs of its population, has planned and projected the future needs for health workers, and is at the point of considering strategies for their production, distribution and retention.

At the same time, a variety of other factors might impede people's access to health services in rural or remote areas, including socioeconomic deprivation, geographical barriers and distance, transport, telecommunications, the cost of accessing services and the acceptability of services. Efforts to address these factors may also influence the availability of health workers in rural and remote areas.

1.4.1. Types of health workers targeted

The recommendations apply to all types of health workers in the formal, regulated health sector (public and non-state), as well as to students aspiring to or currently attending education programmes in health-related disciplines. This includes health-care providers (doctors, nurses, midwives, mid-level health workers, pharmacists, dentists, lab technicians, community health workers, etc.) as well as managers and support workers (human resource managers, health managers, public health workers, epidemiologists, clinical engineers, teachers, trainers, etc.).

1.4.2. Geographical areas covered

These recommendations are specifically aimed at remote and rural areas as opposed to all underserved areas. This is in part because their geographical situation requires specific interventions and because addressing rural and remote areas will also address the needs of underserved populations more broadly, but not vice versa.

Underserved areas are geographical areas where populations have limited access to qualified health-care providers and quality health-care services. They include remote and rural areas, small or remote islands, urban slums, conflict and post-conflict zones, refugee camps, minority and indigenous communities, and any place that has been severely affected by a major natural or man-made disaster. When the recommendations are revised the geographical scope could be expanded to include other underserved areas, if deemed necessary by the expert group and countries.

There are no precise universal definitions for “urban areas” and “rural areas”. According to the United Nations, the distinction between urban and rural population is not amenable to a single definition that would be applicable to all countries because of national differences in the characteristics that distinguish urban from rural areas (16).

Each country's own definition for these terms generally takes into account two main elements: the settlement profile (population density, availability of economic structures) and the accessibility from an urban area (distance in kilometres or hour's drive).

For the purpose of these recommendations, “rural areas” are areas that are not urban in nature (17). An urban area usually incorporates the population in a city or town plus that in the suburban areas lying outside of — but being adjacent to — the city boundaries (18).

1.4.3. Categories of interventions covered

Although there are other ways of increasing the access of populations living in remote and rural areas to adequate health services, for example through different models of service delivery, or through internationally recruited health workers, these recommendations focus only on interventions that are within the remit of human resources planning and management. The four main categories of interventions are:

  1. education
  2. regulation
  3. financial incentives
  4. personal and professional support.

Detailed descriptions of the recommended interventions are provided in Chapter 3.

1.5. Process for formulating the global recommendations

An initial literature search was conducted by WHO in 2008, and a background paper was prepared for the first meeting of the expert group in February 2009. In selecting the members, careful consideration was given to achieving a gender balanced group, with representation from all WHO regions and relevant constituencies (policy-makers, academics, funders, professional associations and rural health workers). Members of the expert group are listed on pages 66–68.

The WHO background paper provides a comprehensive review of the current thinking and evidence in this area and highlights significant knowledge gaps (19). The experts used the background paper to agree on the research questions to be addressed by this report, and on the four categories of interventions. During their first meeting, they also finalized a plan of action to further supplement the evidence base, and some of the experts self-selected into a “core” expert group to undertake the additional systematic research needed. Subsequent expert consultations (two of the core group in April and October 2009, and two of the full expert group in June and November 2009) discussed the results of the additional research and proposed draft recommendations. During these consultations, members of the core expert group provided initial text for the recommendations, which were subsequently revised by the WHO Secretariat (20).

The revised draft recommendations were presented to policy-makers, academics and other stakeholders from 15 Asian countries and eight African countries during a regional workshop in November 2009 in Hanoi, Viet Nam (21). Participants had the opportunity to discuss their experiences and challenges in improving rural and remote retention and to comment on the draft recommendations.

The experts met for the final time in February 2010 to discuss again the draft recommendations, particularly with a view to rank the recommendations based on the quality of the evidence, benefits, values, and resource use. Balance worksheets were prepared for each recommendation, containing the factors taken into account in ranking the recommendations. Follow-up was done by e-mail with the core group on the final evidence tables and on the revised balance worksheets for each recommendation. The WHO Secretariat incorporated the experts' inputs and finalized the report.

Several papers that informed the development of this report were published in May 2010 in a special theme issue of the Bulletin of the World Health Organization, a peer-reviewed journal (22). In addition, two experts were commissioned to write reports on compulsory service schemes and outreach services in order to review and analyse available evidence related to these specific recommendations. Another expert conducted a “realist review” of a selection of retention studies with the aim of better understanding the influence of contextual factors and the mechanisms that make interventions work or fail. Comprehensive country case studies were also conducted in Australia, Ethiopia, the Lao People's Democratic Republic, Mali, Norway, Samoa, Senegal, Vanuatu and Zambia in order to understand country specificities and to share lessons learnt. These reports and country case studies were a significant contribution to the evidence base for these recommendations and will all be published as standalone documents and will be accessible online at: http://www.who.int/hrh/resources/.

1.6. Dissemination process

The document will be printed and made available on the WHO web site, as well as on CD-ROM, and will be circulated through WHO channels for adaptation and implementation at country level. It will also be translated and subsequently disseminated. The recommendations given in this document are expected to remain valid until 2013. The Health Workforce Migration and Retention Unit in the Department of Human Resources for Health at WHO Headquarters in Geneva will be responsible for initiating a review of these global recommendations at that time, based on new evidence and research and feedback from countries that have been using the recommendations. The possibility to expand the scope of the recommendations, for example, to include recruitment and retention strategies for all underserved areas, shall also be considered.

1.7. Methodology

These recommendations were developed following a comprehensive review of all relevant and available evidence related to health workforce attractiveness, recruitment and retention in remote and rural areas. Much of the evidence in this field comes from observational studies, rarely from well-designed cohort studies or before-and-after studies. Unlike clinical medicine, it is quite difficult, if not impossible, to conduct randomized controlled trials to understand the effects of many of the interventions proposed in this document. These are complex interventions with multiple outcomes, and many confounders detract from the design of the interventions, and intervene during the implementation phase. The expert group considered that in this field it is equally important to understand whether an intervention works or not (effectiveness), and also why it works and how. Context is a key element that can be responsible for different outcomes or results from the same intervention and thus needs to be better captured in the research on these interventions.

All efforts were made to comply with standards for reporting, processing and using evidence in the production of WHO guidelines as required by the Organization's Guidelines Review Committee (GRC) (23). This includes using a system for assessing evidence for interventions known as GRADE (Grading of Recommendations Assessment, Development and Evaluation) and presenting the quality of the evidence in the GRADE format.

Because of the richness of the information in this field, particularly with regard to the mechanisms that make interventions work, the expert group felt that a considerable amount of valuable evidence was not being captured by GRADE. As a result, early on in the process of formulating these recommendations the experts decided to supplement the GRADE tables with an additional table to ensure policy-makers had access to summaries of all relevant existing evidence. See pages 62-65 for full details about the methodology for the literature review, additional research, evidence gathering and assessment.

1.8. Structure of the report

This chapter provides the rationale and describes the process for the development of the global recommendations on the retention of health workers in remote and rural areas. The remaining five chapters of the report address what should be done and why, based on an extensive literature review, expert opinion and the consultative process:

  • the principles and actions that should guide national strategies to improve retention of health workers in remote and rural areas (Chapter 2)
  • the specific recommendations grouped in four main categories (Chapter 3)
    -

    education

    -

    regulation

    -

    financial incentives

    -

    personal and professional support

  • how to select and evaluate the interventions (Chapter 4)
  • the research agenda and action plan (Chapter 5)
  • details of the criteria used to rank each of the recommendations presented in Chapter 3 (Chapter 6).

The annexes, which are available on CD-ROM, as well as online, include details of the evidence and information used in the formulation of the recommendations:

  • the evidence profiles for the recommendations A1A5, B1B3, C1 and D1D6 (Annex 1)
  • a comprehensive table containing descriptive evidence not included in the evidence profiles (Annex 2)
  • Resolution WHA63.16 and the WHO Global Code of Practice on the International Recruitment of Health Personnel (Annex 3).
Copyright © 2010, World Health Organization.

All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: tni.ohw@sredrokoob). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: tni.ohw@snoissimrep).

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