| Abstract|| |
Background: Worldwide, rural inequitable distribution and dearth of health professionals pose poor functioning of health services. In this study, we gather interventions aimed at increasing the proportion of health professionals working in rural and remote areas. Methods: We searched PUBMED, MEDLINE, EMBASE and google scholar database with key words such as “doctors”, “nurses” “health workers”, “health care professionals” and “human resources for health”. Further, comprehensive data base of relevant literature on recruitment or retention or both, of health workers in rural and remote areas has been searched through the websites of different government, non-government, national and international agencies. Results: We found that, there are mainly four interventions employed for improved rural retention. These interventions are generally grouped into educational, financial, regulatory, personal and professional strategies. We also judged the effectiveness of the intervention provided in the literature. Conclusion: Currently, there is limited reliable evidence regarding the effects of these interventions aimed at addressing the maldistribution of health professionals. Hence, well-designed observational studies are needed to confirm that educational, financial, regulatory, personal and professional strategies might influence the health workers' decision to stay in underserved areas. Further, the state governments, public health schools and medical colleges should ensure that when interventions are implemented, their impacts can be measured through scientifically rigorous approaches to establish the true effects of these measures for improved rural recruitment and retention.
Keywords: Health worker, human resources for health, nurses, physicians, primary health care, recruitment, retention, rural retention
|How to cite this article:|
Behera MR, Prutipinyo C, Sirichotiratana N, Viwatwongkasem C. Interventions for improved retention of skilled health workers in rural and remote areas. Ann Trop Med Public Health 2017;10:16-21
|How to cite this URL:|
Behera MR, Prutipinyo C, Sirichotiratana N, Viwatwongkasem C. Interventions for improved retention of skilled health workers in rural and remote areas. Ann Trop Med Public Health [serial online] 2017 [cited 2018 Mar 21];10:16-21. Available from: http://www.atmph.org/text.asp?2017/10/1/16/205591
| Introduction|| |
Globally, the inequitable distribution and low availability of health-care professionals have led poor functioning of health services., Approximately, half (50%) of the global population resides in rural regions, which is served by only 23% of the healthcare professionals, of which 24% belong to total medical doctors workforce and 38% comprises total nursing work force.,, In Australia, 4.0 physicians per 1000 population live in main urban cities, whereas as in remote and very remote areas it is 2.4 physicians per 1000 population. In Canada, metropolitan areas have 2.6 physicians per 1000 population and rural areas have 0.9 doctors per 1000 people. The most populous county in the world, China shows a similar statistic towards maldistribution of qualified health workers in rural versus urban areas, with 7.62 health technicians per 1000 population in urban regions and 3.04 health technicians per 1000 population in rural regions. In low and middle income countries (LMIC), the unequal distribution of health-care professionals is even greater, leading to poor health outcomes. For example, in South Africa, around 44% of the rural inhabitants are served by only 12% of physicians and 19% of nurses.,, In Dakar, the capital of Senegal, 60% of physicians work where only 23% of population live, whereas in Ghana, 44% of the population is served by 87% of the urban doctors.
The inequitable distribution of health-care professionals across globe has resulted in underproduction among health workers. Net migration to high income countries is also a major concern. For instance, in one World Health Organization (WHO) cluster region, such as the America, 37% of health workforce accounts for only 10% global burden of disease. Regarding the African regions of WHO cluster, 3% of health workforce accounts for 24% of the global burden of disease. Further, the highest global burden of disease lies in the African continent, which face the worst distribution of health workers (2.3 health workers per 1000 population) and lowest health care expenditure by the governments (29.5%) towards the salaries of health workforce. It has been estimated that there is a 10.3 million global shortage of health workers in the world, out of which 7 million are required in rural parts and rest 3.5 million in urban areas. In Africa, 50% of urban dwellings and 70% of rural inhabitants lack access to basic primary health care services because of human resource scarcity. Further, in Africa, approximately 800,000 additional skilled health workers (doctors, nurses and midwives) are needed by 2015 in 31 African countries.
In 2010, the World Health organization (WHO) addressed the long standing problem of the acute shortages of health workers and then developed evidence based recommendations for improved retention of health-care practitioners in remote and rural areas in 4 policy domains: (1) education (2) regulatory (3) financial incentives (4) professional and personal support [Table 1]. The recommendation made by WHO and its early implementation have been studied and discussed on international levels.
|Table 1: World Health Organization recommendations to improve the recruitment and retention of health workers in remote and rural areas|
Click here to view
In this paper, we describe a brief overview of the current strategies that can generally be grouped into educational, financial, regulatory, personal, and professional strategies for improved rural retention. Further, how these strategies might work and implemented in different parts of the country, with comments are presented in [Table 2]. We searched PUBMED, MEDLINE, EMBASE and google scholar data base with key words such as “doctors”, “nurses”, “health workers” “health care professionals” “human resources for health”. Further, comprehensive data base of relevant literature on recruitment or retention, or both, of health workers in rural and remote areas has been searched through the websites of different government, non-government, national and international agencies. This report is mainly focused on skilled health workers, such as medical doctors, nurses, pharmacist, physiotherapist, dentist and occupational therapist. We excluded the studies of those concerning lay health workers (i.e non-professionals).
|Table 2: Examples of current strategies to address the acute shortages of health professionals|
Click here to view
Description of the intervention and how the intervention might work
WHO recommends inclusion of rural students in medical and nursing colleges, and suggests that establishing more medical and nursing institution in rural areas would bolster better orientation towards rural health needs. A number of countries across the world have focused on recruiting rural students to enhance health providers' distribution in rural and remote areas. Evidence from the retrospective studies found that rural background students, who wish to take on rural medicine in medical schools during studies, show a greater likelihood of working and retaining in rural areas.,,,,, The WHO report in 2010 presented a moderate evidence that medicine students who belong to rural settings were more likely to stay and serve in the underserved locations upon graduation. Such evidence was gathered from other studies review, and literature.,, Also, a number of countries have implemented special rural health and primary health care programmes in medical schools. All these programmes are focused on recruiting rural background students who have expressed keen interest to practice rural family medicine upon graduation. Further, a positive correlation, found among these programmes and rise in number of allopathic doctors to work in rural areas, has been reported in many observational studies.,,
Various nations have also constituted medical colleges and family medicine programmes in rural and remote areas and encouraged students to enter these programmes and serve in underserved populations upon graduation. In Australia, Rural Clinical Schools have been established in 2000/2001, where rural based clinical training has been imparted to undergraduates to improve rural retention and recruitment of health-care professionals., In Congo, one study has shown that 81% of graduates were employed in their own provinces rural and remote areas upon completion of rural medicine training. Only 26% of the students who completed their studies from city medical schools worked in underserved areas.
Various types of coercive strategies have been adopted in many countries to address shortages of health professionals for the short term. For example, restricting foreign recruited physicians to rural practice and compulsory community service programmes has been introduced by some governments to address the rural retention problems., There are also various rural service compulsory programmes adopted in different parts of certain countries to retain health-care professionals. Frehywot 2010 reviewed these compulsory service programmes and found that more than 70 countries including Mexico, Norway, Russia, Educator, Congo, Nigeria, Cuba, Bolivia, and Ghana have implemented these programmes; however the effectiveness of compulsory service programme has not been effectively measured by most of these countries. Hence, the outcome of this study has a mixed result with respect to rural retention of health workers. Further, health-professionals studied were not likely to continue working in the same job after completion of mandatory rural service period. Hence, some compulsory rural service programmes have been found to be an impediment to the continuity of care provided to community. This negative experience may cause an adverse effect towards career decisions of health workers to stay in remote locations. Other international studies have also highlighted the inclusion of compulsory rural service with other incentive measures and support mechanisms, such as a motivational factor for health workers to stay in rural areas., Now, number of countries have implemented incentivized compulsory rural service for a certain period in rural and undeserved locations to ensure more equitable distribution of primary health care.,,, Further, developed countries have attempted to recruit foreign physicians and nurses from poorer countries for rural service,,, ignoring the negative consequences on the provision of health services in their own country. Coercive strategies may also provide solutions for a shorter period; however, long term affects are unknown, as these strategies may prove counterproductive and alienate health workers for rural practice.
Financial incentives strategies
Financial incentive strategies for improving rural retention include mainly loan repayment and scholarship that are linked to rural service commitments., Further, higher salaries for health workers, rural retention grants, and rural allowances, have been introduced in many countries. The effectiveness of financial incentives on the rural retention and recruitment of health workforce are based on cross-sectional, descriptive surveys, and retrospective cohort studies. A systematic review conducted in 43 countries studies (9 studies from the Canada, South Africa, Japan and New Zealand and 34 studies from the USA), on the financial incentives for the return of service to rural areas, has found that financial incentives were mainly related to scholarships and loan repayment schemes, and mainly belong to observational studies. Also, the effectiveness of financial incentives has shown a limited role, especially when nominal monetary incentives are given to health-care professionals. Sempowski (2004) conducted a systematic review of 10 studies and investigated the impact of financial incentives in exchange for return of rural service commitments. He found that although long term impact was not clear, short term benefits may be realized for financial return of serviceprogramme. Further, one cohort study, comprised in this review, mentioned that doctors who opted voluntary rural service were more likely to stay in underserved locations than those doctors serving in remote areas due to return of service commitments.
The rural allowances have been introduced by various governments as a motivational factor to retain and attract rural health workers. The impact of additional allowance in the rural areas is being evaluated by a questionnaire based survey.
Personal and professional support strategies
Questionnaire-based surveys have indicated that various strategies on personal and professional levels have been attempted for health professionals for rural practice. For example, better health service management, provision of ongoing training, and professional development were crucial factors for influencing health workers toward work in rural areas. Career development opportunities and continued training and higher education were found to be an important motivational factor for healthcare professional retention in underservedareas. However, inadequate school education for children, lack of health care facilities and poor living conditions were consistently found to be a significant obstacles for rural health workforce. The WHO technical report also mentioned the availability of scarce information on the impact of professional development intervention among health workers working in underserved areas. Further one review concluded that the effectiveness of professional and personal support intervention requires change on practitioner behaviour, patient outcomes, or service outcomes.
| Conclusion|| |
Currently, there is limited, reliable evidence to measure the impact of interventions aimed at augmenting the proportion of health-care-professionals in rural and remote areas. Despite scarce information, medical institutions and governments across the world have implemented numerous strategies for improved rural retention. These strategies, however, require rigorous evaluation, so that true effectiveness can be measured. Further, several factors are involved in the health workers consideration of job choices for rural service, which varies across settings. Hence, well-designed observational studies are needed to develop effective educational, financial, regulatory, personal, and professional interventions to guide these tailored interventions and identify more generalizable principles regarding the health workers' decisions to stay in rural and underserved locations.
This study is a part of the doctorate research work by Manas Ranjan Behera towards partial fulfillment of the requirements for the degree of Doctor of Public Health, Faculty of Graduate Studies, Mahidol University.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Scheil-Adlung X. Global evidence on inequities in rural health protection: new data on rural deficits in health coverage for 174 countries. International Labour Office, Social Protection Department: Geneva, ILO 2015; Extension of Social Security Series no 47.
Viscomi M, Larkins S, Gupta TS. Recruitment and retention of general practitioners in rural Canada and Australia: a review of literature. Can J Rural Med 2013;18:13-23.
Chen Y, Yin Z, Xie Q. Suggestions to ameliorate the inequity in urban/rural allocation of healthcare resources in China. Int J Equity Health 2014;13:34.
Statistics South Africa. People of South Africa: population census, 1996. Available from: http://www.statssa.gov.za/
. [Last accessed on 2016 January 29].
Zurn P, Codjia L, Sall FL, Braichet JM. How to recruit and retain health workers in underserved areas: the Senegalese experience. Bull World Health Organ 2010;88:386-9.
Dussault G, Franceschini MC. Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce. Hum Resour Health 2006;4:12.
Mullan F. The metrics of the physician brain drain. N Eng J Med 2005;353:1810-8.
Scheffler RM, Mahoney CB, Fulton BD, Dal Poz MR, Preker AS. Estimates of health care professional shortages in sub-Saharan Africa by 2015. Health Aff (Millwood) 2009;28:w849-62.
Buchan J, Couper ID, Tangcharoensathien V, Thepannya K, Jaskiewicz W, Perfilieva G. et al. Early implementation of WHO recommendations for the retention of health workers in remote and rural areas. Bull World Health Organ 2013;91:834-40.
de Vries E, Reid S. Do South African medical students of rural origin return to rural practice?. S Afr Med J 2003;93:789-93.
Rabinowitz HK, Diamond JJ, Markham FW, Hazelwood CE. A program to increase the number of family physicians in rural and underserved areas: impact after 22 years. JAMA 1999;281:255-60.
Rabinowitz HK, Diamond JJ, Veloski JJ, Gayle JA. The impact of multiple predictors on generalist physicians' care of underserved populations. Am J Public Health 2000;90:1225-8.
Rabinowitz HK, Diamond JJ, Markham FW, Paynter NP. Critical factors for designing programs to increase the supply and retention of rural primary care physicians. JAMA 2001;286:1041-8.
Western J, Makkai T, McMillan J, Dwan K. Issues for rural practice in Australia. General Practice Evaluation Program, 2000. Commonwealth Department of Health and Aged Care, Report no 535.
Woloschuk W, Tarrant M. Does a rural education experience influence students' likelihood of rural practice? Impact of student background and gender. Med Educ 2002;36:241-7.
Laven G, Beilby JJ, Wilkinson D, McElroy HJ. Factors associated with rural practice among Australian-trained general practitioners. Med J Aust 2003;179:75-9.
Laven G, Wilkinson D. Rural doctors and rural backgrounds: how strong is the evidence? A systematic review. Aust J Rural Health 2003;11:277-84.
Rabinowitz HK, Diamond JJ, Markham FW, Rabinowitz C. Long-term retention of graduates from a program to increase the supply of rural family physicians. Acad Med 2005;80:728-32.
Woloschuk W, Tarrant M. Do students from rural backgrounds engage in rural family practice more than their urban-raised peers?. Med Educ 2004;38:259-61.
Brooks RG, Walsh M, Mardon RE, Lewis M, Clawson A. The roles of nature and nurture in the recruitment and retention of primary care physicians in rural areas: a review of literature. Acad Med 2002;77:790-8.
Moores DG, Woodhead-Lyons SC, Wilson DR. Preparing for rural practice. Enhanced experience for medical students and residents. Can Fam Physicians 1998;44:1045-50.
Curran V, Rourke J. The role of medical education in the recruitment and retention of rural physicians. Med Teach 2004;26:265-72.
Eley DS, Synnott R, Baker PG, Chater AB. A decade of Australian Rural Clinical School graduates–where are they and why? Rural Remote Health 2012;12:1937.
Wilkinson D, Birks J, Davies L, Margolis S, Baker P. Preliminary evidence from Queensland that rural clinical schools have a positive impact on rural intern choices. Rural Remote Health 2004;4:340.
Longombe AO. Medical schools in rural areas–necessity or aberration?. Rural Remote Health 2009;9:1131.
Reid SJ. Compulsory community service for doctors in South Africa – an evaluation of the first year. S Afr Med J 2001;91:329-36.
Cavender A, Alban M. Compulsory medical service in Ecuador: the physician's perspective. Soc Sc Med 1998;47:1937-46.
Frehywot S, Mullan F, Payne PW, Ross H. Compulsory service programmes for recruiting health workers in remote and rural areas: do they work?. Bull World Health Organ 2010;88:364-70.
Marais BJ, de Villiers M, Kruger J, Conradie H, Jenkins L, Reuter H. The role of educational strategies to reverse the inverse performance spiral in academically isolated rural hospitals. S Afr Family Practice 2007;49:15.
Liaw ST, McGrath B, Jones G, Russell U, Bourke L, Hsu-Hage B. A compulsory experiential and interprofessional rural health subject for undergraduate students. Rural Remote Health 2005;5:460.
Omole O, Marincowitz G, Ogunbanjo GA. Perceptions of hospital managers regarding the impact of doctors' community service. S Afr Family Practice 2005;47:55-59.
Ezenwa AO. Health manpower and population change in Nigeria. J Royal Soc Health 1986;106:143-5.
Fadayomi TO, Oyeneye OY. The demographic factor in the provision of health facilities in developing countries: the case of Nigeria. Soc Sci Med 1984;19:793-7.
Kiesouw L. From Cuba to Khayelitsha-experiences of a Cuban doctor in SA. S Afr Med J 1996;86:906-10.
Pathman DE, Konrad TR, King TS, Taylor DH, Koch GG. Outcomes of states' scholarships, loan repayment and related programs for physicians. Med Care 2004;42:560-8.
Scammon DL, Williams SD, Li LB. Understanding physicians' decisions to practice in rural areas as a basis for developing recruitment and retention strategies. J Ambul Care Mark 1994;5:85-100.
Humphreys JS, Jones JA, Jones MP, Hugo G, Bamford E, Taylor DH. A critical review of rural medical workforce retention in Australia. Aust Health Rev 2001;24:91-102.
Ditlopo P, Blaauw D, Bidwell P, Thomas S. Analyzing the implementation of the rural allowance in hospitals in North West Province, South Africa. J Public Health Policy 2011;32:S80-93.
Jackson J, Shannon CK, Pathman DE, Mason E, Nemitz JW. A comparative assessment of West Virginia's financial incentive programs for rural physicians. J Rural Health 2003;19:329-39.
Pathman DE, Konrad TR, Ricketts TC. The comparative retention of National Health Service Corps and other rural physicians: results of a 9-year follow-up study. JAMA 1992;268:1552-8.
Barnighausen T, Bloom DE. Financial incentives for return of service in underserved areas: a systematic review. BMC Health Serv Res 2009;9:86.
Sempowski IP. Effectiveness of financial incentives in exchange for rural and under serviced area return-of-service commitments: systematic review of the literature. Can J Rural Med 2004;9:82-8.
Reid S. Monitoring the effect of the new rural allowance for health professionals. Durban: Health System Trust 2004.
Kotzee TJ, Couper ID. What interventions do South African qualified doctors think will retain them in rural hospitals of the Limpopo province of South Africa?. Rural Remote Health 2006;6:581.
Willis-Shattuck M, Bidwell P, Thomas S, Wyness L, Blaauw D, Ditlopo P. Motivation and retention of health workers in developing countries: a systematic review. BMC Health Serv Res 2008;8:247.
Lehmann U, Dieleman M, Martineau T. Staffing remote rural areas in middle-and low-income countries: a literature review of attraction and retention. BMC Health Serv Res 2008;8:19.
Moran AM, Coyle J, Pope R, Boxall D, Nancarrow SA, Young J. Supervision, support and mentoring interventions for health practitioners in rural and remote contexts: an integrative review and thematic synthesis of the literature to identify mechanisms for successful outcomes. Human Resour Health 2014;12:10.
Dr. Manas Ranjan Behera
Department of Public Health Administration, Faculty of Public Health, Mahidol University, Bangkok
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2]