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
Globally, the inequitable distribution and low availability of health-care professionals have led poor functioning of health services.[1],[2] 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.[1],[2],[3] 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.[4] In Canada, metropolitan areas have 2.6 physicians per 1000 population and rural areas have 0.9 doctors per 1000 people.[5] 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.[6] 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.[7],[8],[9] In Dakar, the capital of Senegal, 60% of physicians work where only 23% of population live,[10] whereas in Ghana, 44% of the population is served by 87% of the urban doctors.[11] 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.[12] 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.[1] 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.[3] 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.[13] 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].[2] The recommendation made by WHO and its early implementation have been studied and discussed on international levels.[14]
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).
Description of the intervention and how the intervention might work Educational strategies 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.[15],[16],[17],[18],[19],[20] 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.[2] Such evidence was gathered from other studies review[21],[22] and literature.[15],[23],[24] 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.[16],[25],[26] 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.[27] 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.[28],[29] 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.[30] Regulatory strategies 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.[31],[32] 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.[33] 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.[33] This negative experience may cause an adverse effect towards career decisions of health workers to stay in remote locations.[34] 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.[35],[36] 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.[31],[33],[37],[38] Further, developed countries have attempted to recruit foreign physicians and nurses from poorer countries for rural service,[7],[31],[39] 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.[40],[41] Further, higher salaries for health workers, rural retention grants,[42] and rural allowances[31],[43] 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[40],[44] and retrospective cohort studies.[45] 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,[46] 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.[47] 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.[47] 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.[48] 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.[49] Career development opportunities and continued training and higher education were found to be an important motivational factor for healthcare professional retention in underservedareas.[50] 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.[51] 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.[2] Further one review concluded that the effectiveness of professional and personal support intervention requires change on practitioner behaviour, patient outcomes, or service outcomes.[52]
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. Acknowledgment 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 Nil. Conflicts of interest There are no conflicts of interest.
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2] |
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