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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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Executive Summary

Why these recommendations?

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. A shortage 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. The World Health Organization (WHO) has produced these recommendations in response to requests from global leaders, civil society and Member States.

What is the scope?

The evidence-based recommendations relate to the movements of health workers within the boundaries of a country and focus solely on strategies to increase the availability of health workers in remote and rural areas through improved attraction, recruitment and retention. As such they complement the current work of WHO on the Global Code of Practice on the International Recruitment of Health Personnel (see Annex 3). The recommendations apply to all types of health workers in the formal, regulated health sector, including health managers and support staff, as well as to students aspiring to or currently attending education programmes in health-related disciplines.

What are the specific recommendations?

It is important to stress that there is much more helpful detail in the body of the report and that the best results will be achieved by choosing and implementing a bundle of contextually relevant recommendations.

    1. Use targeted admission policies to enrol students with a rural background in education programmes for various health disciplines, in order to increase the likelihood of graduates choosing to practise in rural areas.
    2. Locate health professional schools, campuses and family medicine residency programmes outside of capitals and other major cities as graduates of these schools and programmes are more likely to work in rural areas.
    3. Expose undergraduate students of various health disciplines to rural community experiences and clinical rotations as these can have a positive influence on attracting and recruiting health workers to rural areas.
    4. Revise undergraduate and postgraduate curricula to include rural health topics so as to enhance the competencies of health professionals working in rural areas, and thereby increase their job satisfaction and retention.
    5. Design continuing education and professional development programmes that meet the needs of rural health workers and that are accessible from where they live and work, so as to support their retention.
    1. Introduce and regulate enhanced scopes of practice in rural and remote areas to increase the potential for job satisfaction, thereby assisting recruitment and retention.
    2. Introduce different types of health workers with appropriate training and regulation for rural practice in order to increase the number of health workers practising in rural and remote areas.
    3. Ensure compulsory service requirements in rural and remote areas are accompanied with appropriate support and incentives so as to increase recruitment and subsequent retention of health professionals in these areas.
    4. Provide scholarships, bursaries or other education subsidies with enforceable agreements of return of service in rural or remote areas to increase recruitment of health workers in these areas.
    1. Use a combination of fiscally sustainable financial incentives, such as hardship allowances, grants for housing, free transportation, paid vacations, etc., sufficient enough to outweigh the opportunity costs associated with working in rural areas, as perceived by health workers, to improve rural retention.
    1. Improve living conditions for health workers and their families and invest in infrastructure and services (sanitation, electricity, telecommunications, schools, etc.), as these factors have a significant influence on a health worker's decision to locate to and remain in rural areas.
    2. Provide a good and safe working environment, including appropriate equipment and supplies, supportive supervision and mentoring, in order to make these posts professionally attractive and thereby increase the recruitment and retention of health workers in remote and rural areas.
    3. Identify and implement appropriate outreach activities to facilitate cooperation between health workers from better served areas and those in underserved areas, and, where feasible, use telehealth to provide additional support to health workers in remote and rural areas.
    4. Develop and support career development programmes and provide senior posts in rural areas so that health workers can move up the career path as a result of experience, education and training, without necessarily leaving rural areas.
    5. Support the development of professional networks, rural health professional associations, rural health journals, etc., in order to improve the morale and status of rural providers and reduce feelings of professional isolation.
    6. Adopt public recognition measures such as rural health days, awards and titles at local, national and international levels to lift the profile of working in rural areas as these create the conditions to improve intrinsic motivation and thereby contribute to the retention of rural health workers.

What principles should guide the formulation of national rural retention strategies?

A number of interconnected principles should underpin all efforts to improve the recruitment and retention of health workers in remote and rural areas. Adhering to the principle of health equity will help in allocating available resources in a way that contributes to the reduction of avoidable inequalities in health. And grounding rural retention policies in the national health plan will provide a framework for holding all partners accountable for producing tangible and measurable results.

The choice of interventions should be informed by an in-depth understanding of the health workforce. This requires, at a minimum, a comprehensive situation analysis, a labour market analysis, and an analysis of the factors that influence the decisions of health workers to relocate to, stay in or leave rural and remote areas. Giving due consideration to the broader social, economic and political factors at national, subnational and community levels that influence retention will help to ensure the choice of policy interventions are anchored in and tailored to the specific context of each country.

Assessing options and championing interventions to improve rural retention of health workers will require human resource management expertise at the central and local levels, while implementation of the chosen policies will require individuals with strong management and leadership skills, especially at the facility level. Engagement of stakeholders across several sectors is a critical element for the success of rural retention policies, as it is for any type of health system or health workforce policy. Rural and remote communities, professional associations and other relevant decision-makers must be included from the beginning to obtain and maintain the support of all involved.

A commitment to monitoring and evaluation and to operational research is essential in order to evaluate effectiveness, revise polices as necessary once implementation is underway, capture valuable lessons learnt, build the evidence base, and improve understanding about how interventions work and why they work in some contexts but fail in others.

How to select and evaluate the interventions?

As in many areas of health systems policies, sound evaluations of rural retention interventions are lacking. In order to support the needed paradigm shift towards more and better evaluations, this report proposes a framework and five questions to guide policy-makers in the selection, design, implementation and monitoring and evaluation of appropriate rural retention interventions.

  1. Relevance: which interventions best respond to national priorities and the expectations of health workers and rural communities?
  2. Acceptability: which interventions are politically acceptable and have the most stakeholder support?
  3. Affordability: which interventions are affordable?
  4. Effectiveness: have complementarities and potential unintended consequences between various interventions been considered?
  5. Impact: what indicators will be used to measure impact over time?

The framework specifies the dimensions on which effects of retention strategies can be measured: attractiveness, recruitment, retention and health workforce and health systems performance. One of the challenges in evaluation is that each recommendation has more than one outcome (or effect), and no outcome can be achieved through only one intervention. This complexity adds to the task of measuring the results and attributing the achieved effects to specific interventions.

How were the recommendations formulated?

The WHO Secretariat convened a gender-balanced group of experts comprised of researchers, policy-makers, funders, representatives of professional associations and programme implementers, drawn from each of the WHO regions. The expert group was asked 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.

The 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. They have also been informed by country experiences and judgements of the experts, who met six times between February 2009 and February 2010. 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 may 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). 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. But, because of the richness of the information in this field, particularly with regard to the mechanisms that make interventions work, the expert group decided to supplement the GRADE approach with additional evidence.

Various supporting materials are being published by the WHO Secretariat alongside this document.

  • Annexes on CD-ROM include details of all the evidence that was used in developing the recommendations (GRADE evidence profiles, descriptive evidence tables).
  • Several papers that informed the development of this report were published in May 2010 in a special them issue of the Bulletin of the World Health Organization.
  • Three commissioned reviews have been published by WHO: a review of the impact of compulsory service on the recruitment and retention of health workers in rural areas; a “realistic” evaluation that sought to understand not only whether certain interventions worked or not, but also why and how; and a review of the role of outreach support on the recruitment of health workers in remote and rural areas.
  • A series of comprehensive country case studies are being published including reports from Australia, China, Ethiopia, Lao People's Democratic Republic, Mali, Norway, Samoa, Senegal, Vanuatu and Zambia.

What's next?

The document is available in print, on the WHO website and on CD-ROM, and it will be circulated through WHO channels for adaptation and implementation at country level. It will also be translated and subsequently disseminated. Some countries, including the Lao People's Democratic Republic and Mali, are already considering these recommendations to inform the design of their retention strategies, with the WHO Secretariat providing technical assistance, as required. In addition, several members of the expert group are leading a research effort to fill some of the evidence gaps that have emerged through the development of this document.

The recommendations 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 revision of these global recommendations by 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.

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).

Bookshelf ID: NBK138612


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