Any other interventions that could attract and/or provide support (financial, social, logistical, academic) for students from rural backgrounds to successfully complete training to become health workers.
Any other interventions that could provide support to developing or maintaining health professional schools in more rural areas (policies, finances, logistics, etc.).
Any other interventions that could support the development, implementation or supervision of clinical rotations in rural areas during health professional studies.
Any other interventions that could support the development, implementation or evaluation of curricula that reflect rural health issues.
Any other interventions that could support the development, implementation or evaluation or continuous professional development activities for rural health workers.
Any other interventions that could support the development, implementation or evaluation of an enhanced scope of work for rural health workers.
Any other interventions that could support the introduction, training, scale up, support or evaluation of new cadres of rural health workers.
Any other interventions that could support the development, implementation, or management of compulsory service programs for rural health workers.
Any other interventions that could support the development, implementation, or management of subsidized education service programs for health workers in exchange for their service to rural and remote areas.
Any other interventions that could support the development, implementation, management, or evaluation of financial incentives for rural health workers.
Any other interventions that could support the development, implementation, management, or evaluation of living conditions for health workers and their families in rural and remote areas.
Any other interventions that could support the development, implementation, management, or evaluation of working conditions for health workers in rural and remote areas.
Any other interventions that could support the development, implementation, management, or evaluation of outreach support for health workers in rural and remote areas.
Any other interventions that could support the development, implementation, management, or evaluation of career development programs for health workers in rural and remote areas.
Any other interventions that could support the development, implementation, management, or evaluation of professional networking for health workers in rural and remote areas.
Any other interventions that could support the development, implementation, management, or evaluation of public recognition activities for health workers in rural and remote areas.
Facilitate Knowledge Exchange
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.
Health workers’ need for continuous professional stimulation is all the more relevant in rural
or remote areas, where professional isolation can negatively influence performance. Therefore,
supporting professional networking and academic activities, including specialized journals with a
focus on rural areas, can prove beneficial for rural health workers.
Some evidence shows that rural professional associations have increased the retention of health
workers in rural areas. For example, in Mali, young doctors who were supported by the professional
association, “Association des Médecins de Campagne”, remained in rural areas for an
average of four years; the retention rate was lower for those who did not have this support.
The “Rural Doctors Society and Foundation” in Thailand has had several positive effects on the
profile and impact of rural physicians.“ Apart from supporting rural health services, the society
has also actively supported public health movements, such as a national drug policy, an essential
drugs list and tobacco control. It has also played an active role in the national movement toward
democratization and political reform as well as a watchdog role to counteract corruption and
inappropriate administrative behavior”.
In addition to professional associations, other types of support programs can be envisaged.
For example, the “Dr Doc“ program launched in South Australia in 2006 has set up various
support mechanisms such as telephone consultations, crisis support, links to urban general
practitioners (GPs) who provide health care for rural GPs and their families, as well as country
practice retreats to allow rural GPs some rest and relaxation. This has reportedly reduced the
number of rural physicians who want to leave their practice.
This approach is likely to have larger effects if associated with other interventions, such as A5
(continuing education), D1 (improved living conditions) and D2 (safe and supportive working
environment).
Champions may be required in countries to initiate and sustain the development of professional
associations. If these associations are only supported by membership fees, they can be vulnerable
to long-term sustainability issues.
Excerpted from the WHO Global Policy Recommendations, 2010
Raise the Profile of Rural Health Workers
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.
Recognition from managers, peers and the public is one of the main motivating factors in health care
and in other industries. But in the case of rural health, the evidence on public recognition comes
mainly from case studies of individual health workers who have dedicated their lives to serving rural
communities, for which they have received numerous public recognition awards.
Whether these awards made them stay longer or whether intrinsic motivation factors contributed to their
long-term service in rural areas is difficult to say. Nevertheless, it is likely that simple public recognition
measures, such as titles, medals or awards can go a long way in raising the status and morale of
rural health workers and thus contribute to their retention in these areas. Such public recognition
measures are an occasion to focus attention on individual health workers and their achievements,
thereby demonstrating political support for rural health workers and rural health work.
This intervention is relatively inexpensive and can be an important step in improving the recognition of rural health workers. Awards can be offered by health services, professional organizations,
regional governments, national governments and international organizations.
Integral to the success of this recommendation is the need to promote the award or title. In
addition, publishing and bringing the spotlight on rural health worker stories ensures that
information on these role models is distributed throughout the population and may motivate
students or new graduates to work in rural areas. This also increases the prestige of such awards
to the recipient.
Excerpted from the WHO Global Policy Recommendations, 2010
Design Career Ladders for Rural Health Workers
Develop and support career development programs 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.
A career ladder provides a sequence of posts, from the most junior to the most senior, which
health workers can climb up as they advance in their jobs. This is particularly relevant in the
public sector and civil service where a clear sense of hierarchy is the rule.
There is no direct evidence that setting up career ladders in rural areas can help to retain health
workers. However, evidence from surveys shows that clear career prospects are important factors
in the choice of health workers to practice or not in a remote or rural area. Career
ladders are common in urban and hospital settings, but it is possible to develop clear and specific
career paths in rural settings as well. The figure below shows examples of potential steps in career
ladders for various health professions.
Examples of career ladders for health workers:
Nursing |
Allied clinical |
Pharmacy |
- Registered nurse
- Enrolled nurse
- Patient care technician
- Nurse aide
|
- Radiological technologist
- Clinical laboratory technician
- Surgical technician
- Sterile processing
|
- Pharmacist
- Pharmacy technician
- Pharmacy assistant
- Dispensary clerk
|
Excerpted from the WHO Global Policy Recommendations, 2010
Foster Interaction Between Urban and Rural Health Workers
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.
In addition to improved working conditions and supportive supervision, there is also the possibility
to provide outreach support to rural health workers. One form of outreach support is when
individual specialists or teams of specialists make regular visits to their rural peers to advise and
assist with patient care and their professional development. Another form is telehealth, where
distance-based technology is used to help rural health workers diagnose and treat patients and
improve their knowledge and skills.
There is no direct evidence that outreach support programs improve rural or remote retention.
However, there is ample supportive evidence from observational studies that such programs
improve competencies and job satisfaction of rural health workers. They can also contribute
to improving local quality of care, reduce the number of consultation visits to specialists and
lower the rate of hospital admissions.
Outreach activities can, among other things, reduce feelings of professional isolation. They are
likely to be more beneficial in settings where there is a critical shortage of health workers, limited
infrastructure or very sparse populations, as it provides a service that otherwise would not be
available (e.g. mobile clinics or fly-in services).
Implementing outreach support activities, and particularly telehealth programs, requires
significant financial resources, as well as access to the Internet and other technologies. But rapid
advances in telecommunications, in particular in the use of mobile phones, offers hope for more
rapid and widespread implementation of such programs in the near future.
More studies are needed on the role of telehealth and outreach programs on the retention of
health workers.
Excerpted from the WHO Global Policy Recommendations, 2010
Ensure the Workplace is Up to an Acceptable Standard
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.
To what extent improving the working environment has directly improved retention in rural areas
is unclear. However, according to a Cochrane systematic review, “questionnaire-based surveys
suggest that professional and personal support may also influence health professionals’ choice
to work in underserved areas. Professional development, ongoing training and style of health
service management were important factors influencing retention of health professionals in
underserved areas”.
Supportive evidence from satisfaction surveys shows that health professionals are disinclined to
apply for or accept assignments to practice in facilities that are in a state of disrepair and that do
not have basic supplies, such as running water, gloves, elementary basic drugs and rudimentary
equipment, because this dysfunctional work environment severely limits their ability to practice
what they have been trained to do. In addition, supportive supervision is also a key
element that contributes to improved job satisfaction, performance and subsequent retention
and practise in rural areas.
Improving working conditions is likely to improve the performance and productivity of health
workers, and hence the performance of health systems. But there is a risk that if pilot programs
are implemented in just some rural areas of a country, these will attract health workers from
other areas, thereby re-enforcing existing imbalances.
In terms of costs, equipping and refurbishing health facilities may be resource-intensive, but
benefits can be achieved for a longer period. Likewise, changes in management style and
implementing supportive supervision may also require significant investment in management
training courses and in effective supervision processes, but long-term benefits can be expected.
Finally, holistic strategies to prevent workplace violence can also be complex and costly, but it is
likely they will contribute to improved job satisfaction for the long run.
Excerpted from the WHO Global Policy Recommendations, 2010
Pay Attention to Living Conditions
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.
The absence of direct evidence that improving rural health infrastructure and living conditions
contributes to increased retention of health workers in rural areas is mainly because few large-scale
programs have been implemented. On the other hand, there is ample supportive
evidence. In studies that aim to elicit the factors that influence decisions to work in a remote or rural area, the availability of good living conditions is always mentioned as very important. This
includes accommodation, roads, electricity, running water, Internet access, schools for children
and employment opportunities for spouses.
A study of South African doctors listed better accommodation as one of the three most important
factors that would influence them to remain in a rural area. A study in Bangladesh
revealed that remoteness and difficult access to health centers were major reasons for health
worker absenteeism, while health personnel working in villages or towns with roads and
electricity were far less likely to be absent.
Anecdotal data reinforce the results of studies indicating that the lack of appropriate housing, electricity and phone service, and inadequate schools, all act as disincentives for rural service. Given that this intervention is always part of a larger retention package or scheme of so-called “non-financial incentives”, it is difficult to isolate its individual effect on retention.
Improving rural infrastructure is part of the overall economic development of rural and remote areas.
It is an investment that, among other things, will help to improve health worker retention and have
similarly beneficial effects on workers from other public sectors such as teachers and policemen. It will
also create a more attractive environment for private activities in all economic sectors.
Excerpted from the WHO Global Policy Recommendations, 2010
Make it Worthwhile to Move to a Remote or Rural Area
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.
Several studies point to salaries and allowances as two of the key factors that influence health
workers’ decisions to stay in or leave a rural workplace.
Financial incentives are widely used to recruit and retain health workers in remote and rural
positions, and can be implemented relatively quickly. Yet well-designed and comprehensive
evaluations of the effectiveness of financial incentives are rare, and the evidence that is available
suggests mixed results.
In Australia, for example, financial incentives were set up for long-serving
physicians in remote and rural areas and the amount paid varied according to location and
length of service. One of these incentive plans succeeded in achieving a 65% retention rate
of physicians after five years.
In the Niger, financial incentives were responsible for increasing the
percentage of physicians, pharmacists and dentists working outside the capital, Niamey. But two
years after implementation, the proportion of health workers choosing to go to these areas had
not changed significantly (from 42% at the start to 46% after two years).
Other studies have shown positive effects of financial incentives on increased attractiveness
of rural areas. A survey in South Africa found that 28% to 35% of rural health workers who
received the rural allowance believed it affected their career plans for the next year. A
mid-term review of the Zambian Health Workers Retention Scheme found that within two years
of implementation, the scheme had been able to attract and retain more than 50 doctors in rural
areas, some to areas where there were previously no doctors available.
Prior to implementing financial incentives, significant work needs to be done to fully understand
the opportunity costs of working in remote and rural areas as the incentives need to be carefully matched to the demands and expectations of health workers. Feasibility studies, such as discrete
choice experiments and a labor market analysis, are essential to inform the design of a financial
incentives scheme.
Policy-makers need to be aware of potential sensitivities surrounding giving health workers specific
financial incentives and the problems this may cause between them and other civil servants (if in
a civil-service system) or those health workers not covered under the scheme. For example, the
rural ranking scale in New Zealand caused serious discord between physicians over the definition
of “rural“. Some felt they had been unfairly categorized and some even claimed they had been
financially disadvantaged under the new payment system.
A financial incentive scheme will be more cost effective in countries with a significant surplus
of health workers in major cities because underemployed or unemployed health workers could
be attracted to rural areas at a lower social cost than already employed health workers.
For example, providing incentives can have different results in different contexts: in the Niger, the
shortage of physicians made it nearly impossible to use incentive payments as a trigger for
physicians to relocate in rural areas as the urban market offered sufficient space for private
practice and incomes were much higher.
This is in contrast to Mali, where an oversupply of medical doctors made it attractive for unemployed young doctors to practise in rural areas when offered incentives to relocate. The differences in results of payment of incentives demonstrate the importance of including the labour market in the situational analysis.
The effectiveness of financial incentives could be greater if combined with other interventions,
particularly targeting these at students and health workers with a rural background (A1).
Consideration should also be given to combining these with B2 (different types of health workers, B3 (compulsory service), D1 (improved living conditions) and D2 (safe and supportive
working environment) to ensure increased recruitment and retention of health workers.
More well-designed and comprehensive evaluations need to be conducted in order to determine
the long-term impact of financial incentives on the retention of health workers in remote and
rural areas.
Excerpted from the WHO Global Policy Recommendations, 2010
Tie Education Subsidies to Mandatory Placements
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.
Many governments offer students in the health professions scholarships, bursaries, stipends or
other forms of subsidies to cover the costs of their education and training and in return students
agree to work in a remote or rural area for a certain number years after they become a qualified
health worker.
A systematic review analyzed the effectiveness of financial incentives given in return for medical
service in rural areas. It included 43 studies, of which 34 evaluated programs based in the
USA, while the rest examined programs from Canada, Japan, New Zealand and South Africa.
In these programs, future health workers (i.e. students), or practicing health workers enter
into a contract whereby they receive some sort of financial incentive (either scholarships for their
education, or loans to payback their education, or direct financial incentives), and in exchange
they commit to serve in a rural area for a certain period of time. Usually this intervention is
combined with other types of retention strategies, such as recruitment of students from rural
backgrounds or training in a rurally located school (see Slide 4 on Japan’s “Home Prefecture” recruiting scheme”).
These types of bonding schemes were linked to impressive retention rates in 18 studies: the proportion
of participants who remained in the underserved area after completing their obligated
period of service ranged from 12% to 90%. Yet numerous studies included in this systematic
review had serious methodological flaws and therefore these findings should be interpreted with
some caution.
Bonding schemes appear to be successful in placing significant numbers of health workers
in rural areas, and some even appear effective in ensuring that program participants will
continue to work in other underserved areas after completing their obligatory service. However,
as many offer a “buy-out” option, further information is required to understand how popular
this option is in comparison with completing the compulsory service.
As with other recommendations, positive outcomes are more likely if these return-of-service
agreements are combined with other interventions. For example, combining these incentives
with targeted admissions (A1) is likely to have a larger effect.
Further evidence is required on education subsidies in return of service for nursing students and
other types of health professional students. More needs to be known about the characteristics
of students who commit to return-of-service agreements and why some graduates choose the
“buy-out” option rather than completing their service. More cohort studies should be conducted
to compare the retention rates of health workers who have completed their return of service
with those who graduated without being part of a bonding scheme.
Home prefecture recruiting scheme, Jichi Medical University, Japan
The Jichi Medical University (JMU) in Japan began a new and unique «home prefecture
recruiting scheme» in 1972 with the aim to produce rural doctors and distribute them
nationwide. Students who attend JMU are fully funded by their prefecture government to
study medicine and they sign a contract bonding them to working in their home prefecture
medical institutions for nine years post-graduation, with five to six years of this obligation
spent in rural dispatch areas chosen by their home prefecture. If a contract is breached all
medical school expenses must be paid in one lump sum.
In one part of a well-designed retrospective cohort study, 1477 graduates from JMU were
surveyed in 2000, 2004 and 2006. There was a 95% completion rate and on average,
69.8% of JMU graduates remained in their home prefectures for at least six years after their
obligatory service. Interestingly, if settlement is defined as being in a home prefecture for at
least one out of the three time points, the settlement rate of post-obligation JMU graduates
rises to 76.3%.
Excerpted from the WHO Global Policy Recommendations, 2010
Ensure Rural Retention Policies are Part of the National Health Plan
This is about the principles of alignment and policy coherence at the country level. Rural retention
policies must be grounded in a costed and validated national health plan. A national health plan
provides the framework for holding all partners accountable for producing tangible and measurable
results; it is at the heart of health development that is country-led, country-owned, and fully
aligned with national priorities and capacities.
A national health workforce plan, which is an integral
part of a country’s national health plan, sets out the projected numbers and types of health workers
needed in the future, the policies and strategies to scale up needed health workers, the strategies to
retain and motivate them, and the costs of implementing all the required interventions.
Given that the ultimate goal is to improve health outcomes, it is essential that policy interventions
and plans for producing and allocating the most appropriate types of health workers are developed
to respond to the health needs, perceptions, expectations and health-seeking behaviors of
people living in rural and remote communities.
Any retention strategy should be linked to the broader national and local health system structures
and functions, to take advantage of synergies and increase efficiencies. For example, if a country
has a national health plan and health sector reforms are under way, there may be an opportunity
to prioritize the upgrading of rural health facilities and improve the working environment as part
of a national health facility expansion plan. In contrast, a plan to expand public- or private-funded
health services in urban areas may work against new strategies for attracting people to work in
rural areas.
Excerpted from the WHO Global Policy Recommendations, 2010
Train More Health Workers Faster to Meet Rural Health Needs
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.
Different types of health workers are being used in many countries in order to meet population
health needs in remote and rural areas. For example, a recent survey of sub-Saharan African
countries found non-physician clinicians were active in 25 out of the 37 countries investigated and
concluded: “Low training costs, reduced training duration, and success in rural placements suggest
that non-physician clinicians could have substantial roles in the scale-up of health workforces”.
There is convincing evidence to support the fact that different types of health
workers can lead to improved health outcomes. Many countries heavily rely on
clinical officers, health assistants and other types of health workers to provide health care in
remote and rural areas. The following paragraph highlights the findings from one of the few studies investigating the retention of such workers.
“Técnicos de cirurgia” in Mozambique
Mozambique began to educate and train assistant medical officers with surgical skills
called “técnicos de cirurgia” in 1987. Twenty years later, a study found that 88% of all the
“técnicos” who graduated in 1987, 1988 and 1996 were still working in district hospitals,
compared with only 7% of medical officers who were originally assigned to district hospitals
after graduation. Considering that these “técnicos” perform 92% of all major obstetrical
surgical interventions in rural hospitals, the authors argue that provision of emergency
obstetric care in these areas would be “impossible” without them.
One rationale behind creating different cadres of health workers for remote and rural areas is
that their skills and qualifications may be less marketable than those of highly-trained health
workers, who are also in demand in urban settings, or even outside the country. Another reason
for embracing this policy is that specific types of health workers can be trained to be more
receptive and reactive to local health needs, provided that quality and safety issues are also taken
into account.
In addition, types of health workers that can be trained in a relatively short
period of time may be a more financially viable option in low-resource settings. For increased
recruitment and retention, it is important to consider the use of financial incentives (C1) and
recognition measures for these cadres (D6).
Although different types of health workers are being used in many countries, more research is
needed to understand their retention in remote and rural areas, particularly in comparison with
other, more traditional health cadres, such as physicians. Additionally, more sound evidence is
required on the intentions and factors motivating mid-level cadres in comparison with higher trained
health workers.
Excerpted from the WHO Global Policy Recommendations, 2010
Make the Most of Compulsory Service
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.
Compulsory service is understood as the mandatory deployment of health workers in remote
or rural areas for a certain period of time, with the aim to ensure availability of services in these
areas. It can be either imposed by the government (for positions that are under government
employment), or linked to various other policies. For example, it can be a mandatory requirement
to serve for a certain period of time in remote areas before obtaining the license to practice; or it
can be a prerequisite before applying for a specialization or for career advancement.
A comprehensive review of compulsory service schemes undertaken as part of the development
of these recommendations found that approximately 70 countries have previously used or are
currently using compulsory service. The duration varies from country to country, from a
minimum of one year to a maximum of nine years, and the policies have included almost all
types of health workers.
Despite the popularity of compulsory service, very few evaluations have been conducted in relation
to the retention of health workers either during or post their obligated service period. Studies in
Ecuador and South Africa reveal that although physicians raised serious complaints over
the management of their compulsory service scheme, they did feel that the experience improved
their competencies and had been rewarding overall. In some countries, remote and rural areas are
reliant upon graduates who are complying with their compulsory service obligations. In Thailand,
28 years after the implementation of a national compulsory service strategy, 49.5% of doctors
in rural district hospitals were new graduates, presumably completing their compulsory service
requirements.
Even if only for a limited period of time, health workers completing their compulsory service requirements can significantly increase the availability of health workers in underserved areas. Furthermore, compulsory service periods in remote and rural areas can increase health workers’ appreciation for rural health issues, prove a valuable learning experience, and provide an opportunity to make a difference to the health of people living in underserved and disadvantaged communities.
However, there are notable challenges and risks to implementing a compulsory service requirement
for health workers. In the Indian state of Kerala, for example, large and sustained strikes were
organized in protest of a new three year compulsory service for medical graduates. Compulsory
service can also be criticized for increasing turnover in health centres, and therefore potentially
decreasing the quality of care delivered.
Support and management systems need to be in place to ensure the successful implementation
of compulsory service, and participants need to be appropriately prepared prior to their compulsory
service in order to be able to provide the expected standard of care.
Combining compulsory service with other types of incentives (A5 and C1) and with efforts to improve
the working and living environment of the locations (D1 and D2) is likely to yield better results.
As previously alluded to, more evaluations are required to understand the retention of health
workers in remote and rural areas following the completion of their obligatory service period.
Furthermore, research is required to evaluate compulsory service schemes for health workers
other than physicians.
Excerpted from the WHO Global Policy Recommendations, 2010
Create the Conditions for Rural Health Workers to Do More
Introduce and regulate enhanced scopes of practice in rural and remote areas to increase
the potential for job satisfaction, thereby assisting recruitment and retention.
Health workers serving rural and remote communities may often have to provide services beyond
the remit of their formal training, because of the absence of other more qualified health workers.
In some instances this de facto enhanced scope of practice is recognized through regulatory
measures (decrees, etc.) that allow certain categories of health workers to provide tasks that
are beyond their training, on the assumption that this will increase access to health services for
remote and rural populations.
Whether or not this expanded scope of practice has actually contributed to retention of health
workers is unclear from the current evidence. There is however evidence to show that enhanced
scope of practice can lead to increased job satisfaction. For example, a control study in Australia
found that enrolled nurses who were allowed to prescribe reported higher levels of job satisfaction
than non-medication endorsed nurses.
There is also compelling evidence that quality of care is not diminished when delivered by
health workers with enhanced scope of practice. Indeed, one systematic review found six
randomized controlled trials showing that “quality of care was in some ways better for nurse
practitioner consultations” when compared with physicians, although in non-rural settings. In
addition, patients reported higher levels of satisfaction with nurse practitioners.
Health workers with an enhanced scope of practice can provide vital health-service delivery
particularly in areas with an absolute shortage of health workers. For example, while efforts are
made towards scaling-up the production of physicians, nurse practitioners and mid-level workers
can be used to provide some of the services in the absence of physicians.
Ministries of health need to work with regulatory bodies, professional associations and other
stakeholders in order to clearly stipulate the boundaries and guidelines for expanded scopes of
practices. There may be considerable resistance from certain groups of health workers, and their
concerns and arguments need to be voiced and carefully considered as part of this process.
B1 is often bundled with B2 (different types of health workers).
Combining this recommendation with D6 will help ensure that all those working with an expanded scope of practice are recognized for the contribution and service they are delivering in remote and rural areas. Finally, the attractiveness of relocating to a remote and rural area is likely to increase if the post includes access to further education and training (A5) and financial incentives (C1).
While it has been acknowledged that health workers with enhanced scopes of practice can
contribute effectively to health-service delivery in remote and rural areas, more evidence is
needed to understand whether these health workers are more likely to be retained in these
areas. In addition, little is known about the type of package that is required to recruit and retain
health workers with enhanced scopes of practice.
Excerpted from the WHO Global Policy Recommendations, 2010
Facilitate Professional Development
Design continuing education and professional development programs that meet the needs of rural health workers and that are accessible from where they live and work, so as to support their retention.
Access to continuing education and professional development is necessary to maintain competence
and improve performance of health workers everywhere. However, it may be difficult
for health workers in rural areas to access these programs if it requires travelling to urban
locations.
There is limited direct evidence on the effect of continuing education programs on
retention. But there is ample supportive evidence that if delivered in rural areas, and if focused
on the expressed needs of rural health workers, these programs are likely to improve the
competence of rural health workers, make them feel like they are a part of a professional group,
and increase their desire to remain and practice in those areas.
As for the previous interventions, better results are more likely with a combination of interventions.
To be successful, continuing education needs to be linked to career paths (D4), as well
as with other education interventions. Continuing education should be viewed from a broader
perspective.
Such activities are not only for knowledge acquisition or skills development, they
also provide opportunities for rural health workers to interact with other practitioners and to
maintain professional networks and social contacts, which may help reduce the sense of social
or professional isolation.
Distance learning by means of information and communication
technologies should be used, where appropriate and available, in order to bring continuing
education programmes to more remote locations.
Excerpted from the WHO Global Policy Recommendations, 2010
Match Curricula with Rural Health Needs
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.
Existing evidence in support of this recommendation is generally lacking, particularly in
developing countries and for disciplines other than medicine. However, there is evidence that
education with a primary care focus or a generalist perspective is conducive to producing practitioners
willing and able to work in rural areas. This is because most rural health workers
are generalists or primary care practitioners. In addition, some studies suggest that advanced
procedural skills training (e.g. in obstetrics, emergency medicine, anesthesia and surgery) can
enhance the confidence of family medicine residents and equip them with the requisite skills for
rural practice. This is because rural practitioners often lack specialist support and have a
wider scope of practice.
Practicing in rural areas is associated with three factors: a rural background; positive clinical and
educational experiences in rural settings during undergraduate education; and targeted training
for rural practice at the postgraduate level. However, the individual effects of each of these
factors on improved retention are difficult to estimate, because of many confounders.
Although there is no direct evidence that curricula changes improve rural retention, ample supportive
evidence shows that rurally oriented curricula equip young students with the skills and competencies
necessary to practice in those areas. For example, a small-scale study in Australia was
able to show that when comparing mean percentages of fifth-year exam results, students from
the rural curriculum course gained better results than the urban-based medical curriculum in
several disciplines related to general practice, such as internal medicine, surgery, obstetrics and
gynecology, pediatrics, psychiatry and clinical examination.
Practicing in rural areas is associated with three factors: a rural background; positive clinical and
educational experiences in rural settings during undergraduate education; and targeted training
for rural practice at the postgraduate level. However, the individual effects of each of these
factors on improved retention are difficult to estimate, because of many confounders.
Although there is no direct evidence that curricula changes improve rural retention, ample supportive
evidence shows that rurally oriented curricula equip young students with the skills and competencies
necessary to practice in those areas. For example, a small-scale study in Australia was
able to show that when comparing mean percentages of fifth-year exam results, students from
the rural curriculum course gained better results than the urban-based medical curriculum in
several disciplines related to general practice, such as internal medicine, surgery, obstetrics and
gynecology, pediatrics, psychiatry and clinical examination.
Excerpted from the WHO Global Policy Recommendations, 2010
Train Students Closer to Rural Communities
Locate health professional schools, campuses and family medicine residency programmes outside of capitals and other major cities, as graduates of these schools and programs are more likely to work in rural areas.
Large observational studies from high- and low-income countries show that medical schools located in rural areas are likely to produce more physicians working in rural areas than urbanely located schools. For example, a recent review found that
medical schools in the USA with the following characteristics tend to produce more rural physicians: located in rural states, public ownership, offering training in generalist specialties and receiving little federal research funding. A study
in the Democratic
Republic of the Congo showed that location of a school in a rural area was strongly associated with subsequent employment in the rural area. A study in China showed that rural medical schools produce more rural physicians than medical schools
located in
metropolitan centers.
However, it is often difficult to determine the independent effect of rural location of schools, because research findings tend to be confounded by such factors as recruitment of more rural students in such schools. There is limited evidence
that
graduates from postgraduate residency programs located in rural areas, particularly in family medicine, are also more likely to practice in a rural location, but there are some methodological limitations for this evidence.
Complementary strategies such as distance education and e-learning approaches should be considered as they may allow urban-based schools to extend beyond their usual catchment areas and may give more rural residents access to education without having to relocate to distant cities. Combining this intervention with targeted admissions and curricula changes (A1 and A3) is likely to yield better results.
Some evidence is emerging about the benefits of locating schools for other health professions in rural areas in developing countries as well, but the effects need to be better studied. There is emerging evidence about the importance of promoting a social accountability framework for medical education in underserved areas to better respond to the needs of these communities. For example, several need- and outcome-driven medicals schools in remote or rural areas in Australia, Canada, the Philippines and South Africa formed a network with “a core mission to increase the number, quality, retention and performance of health professionals in underserved communities” ( http://www.thenetcommunity.org/).
Principles of social accountability underpinning the Training for Health Equity Network’s (THENet) medical schools
- Health and social needs of targeted communities guide education, research and service programs.
- Students are recruited from the communities with the greatest health-care needs.
- Programs are located within or in close proximity to the communities they serve.
- Much of the learning takes place in the community instead of predominantly in university and hospital settings.
- The curriculum integrates basic and clinical sciences with population health and social sciences; and early clinical
contact increases the relevance and value of theoretical learning.
- Pedagogical methodologies are student-centered, problem- and service-based and supported by information technology.
- Community-based practitioners are recruited and trained as teachers and mentors.
- Schools partner with the health system to produce locally relevant competencies.
- Faculty and programs emphasize and model commitment to public service.
Excerpted from the WHO Global Policy Recommendations, 2010
Ensure Rural Retention Policies are Part of the National Health Plan
This is about the principles of alignment and policy coherence at the country level. Rural retention
policies must be grounded in a costed and validated national health plan. A national health plan
provides the framework for holding all partners accountable for producing tangible and measurable
results; it is at the heart of health development that is country-led, country-owned, and fully
aligned with national priorities and capacities.
A national health workforce plan, which is an integral
part of a country’s national health plan, sets out the projected numbers and types of health workers
needed in the future, the policies and strategies to scale up needed health workers, the strategies to
retain and motivate them, and the costs of implementing all the required interventions.
Given that the ultimate goal is to improve health outcomes, it is essential that policy interventions
and plans for producing and allocating the most appropriate types of health workers are developed
to respond to the health needs, perceptions, expectations and health-seeking behaviors of
people living in rural and remote communities.
Any retention strategy should be linked to the broader national and local health system structures
and functions, to take advantage of synergies and increase efficiencies. For example, if a country
has a national health plan and health sector reforms are under way, there may be an opportunity
to prioritize the upgrading of rural health facilities and improve the working environment as part
of a national health facility expansion plan. In contrast, a plan to expand public- or private-funded
health services in urban areas may work against new strategies for attracting people to work in
rural areas.
Excerpted from the WHO Global Policy Recommendations, 2010
Get the "Right Students"
Use targeted admission policies to enroll students with a rural background in
education programs for various health disciplines, in order to increase the
likelihood of graduates choosing to practice in rural areas.
There is a compelling body of evidence from high-, middle- and low-income countries that a
rural background increases the chance of graduates returning to practice in rural communities.
Some studies have shown they continue to practice in those areas for at least 10 years.
A Cochrane systematic review states: “It appears to be the single factor most strongly associated
with rural practice”.
Medical schools tend to have high education standards for admission. Countries with a lower level
of secondary education in rural areas compared with urban areas may need to link specific quotas
to admit students from rural backgrounds with academic bridging programs. China, Thailand
and Viet Nam are a few of the countries that have adopted this approach. The long-term solution
is for governments to improve the quality of primary and secondary education in remote and rural
areas.
Students from rural areas may need more financial assistance during their studies, as rural
families often have significantly lower incomes than urban families. They may also need more
academic and social support, because of the transition from a rural to an urban area.
When students from rural backgrounds are trained in schools also located in rural areas, using
curricula that are adapted for rural health needs, they are more likely to return to work in those
areas. Hence, it is important for policy-makers to bundle together at least these three interventions
for a better result (A1 bundled with A2 and A3, and with B4).
More research is needed to understand whether a certain “profile” of a future rural health worker
can be identified: this may be related to geographical origin, gender, specific behavior traits, such as
altruism, or other intrinsic motivation factors. Such knowledge would inform selection and recruitment
policies, as well as counseling of high-school students prior to entering higher education.
Excerpted from the WHO Global Policy Recommendations, 2010
Bring Students to Rural Communities
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.
Undergraduate training, particularly for physicians, is typically conducted in tertiary care institutions using the latest available technology and diagnostic tools. Once medical studies finish, young graduates are left without skills to deal with health situations in areas where advanced technology and tools are not available. The same holds true for other health professions. Clinical placements in rural areas during undergraduate studies is one way to expose students to the health issues and conditions of service within rural communities, and give them a better understanding of the realities of rural health work.
The evidence on the effects of clinical rotations on improved retention is mixed, but it does show that exposure to rural communities during undergraduate studies influences subsequent choices to practice in those areas, even for students with an urban background. These studies, which were conducted for medical, pharmacy and nursing students, also show improved competencies in dealing with rural health issues among students who completed a rural placement during their studies. However, as the rural placements are not always mandatory, there is sometimes the possibility that students from a rural background may self-select for these programs,
bringing potential confounders to the results of the studies.
Rural-based training may allow health workers to “grow roots” in such locations and facilitate the development of professional networks. It may also increase awareness of rural health, even for those who may eventually choose not to practice in a rural area on a permanent basis. The effect can be larger if this intervention is associated with A1 (targeted admission), A2 (location of schools outside major cities) and A4 (changes in curricula). The optimum duration of the rural exposure during undergraduate studies is not known. It varies from four weeks up to 36 weeks of placement, and it can be mandatory or voluntary.
The local availability of mentors, trainers and supervisors is a critical component of this intervention. Stronger study designs are needed to better address confounders in self-selection of students in the rural clinical placement programs. More studies are needed on other types of health workers and from developing countries.
Excerpted from the WHO Global Policy Recommendations, 2010
Education (?)
|
A1
Students From Rural Backgrounds
(?)
- Develop rural recruitment plan or policy (?)
- Provide ongoing management of program (?)
- Conduct regular recruitment visits (?)
- Provide educational support programs for students from rural areas (?)
- Provide stipend for students from rural areas (?)
- Other activities (?)
|
A2 Health Professional Schools Outside of Major Cities
(?)
- Construct new facilities (including school, dormitory, staff housing, etc) (?)
- Equip/furnish school (?)
- Equip/furnish dorms (?)
- Equip/furnish attached health facility (?)
- Ongoing management for attached health facility (?)
- Maintain/repair all facilities (?)
- Other activities (?)
|
A3 Clinical Rotations in Rural Areas During Studies
(?)
- Design and plan program (?)
- Provide ongoing management of program (?)
- Support student cost of rural rotations (?)
- Training for mentors and supervisors during rotation (?)
- Other activities (?)
|
A4 Curricula that Reflect Rural Health Issues
(?)
- Develop rural health curricula (?)
- Disseminate new materials to instructors/trainers (?)
- Prepare new training/education materials (?)
- Other activities (?)
|
A5 Continuous Professional Development For Rural Health Workers
(?)
- Design new education programs for professional development (?)
- Deliver professional development programs (?)
- Support HWs to attend existing training programs (at universities/colleges) (?)
- Other activities (?)
|
Regulatory (?)
|
B1 Enhanced Scope of Practice
(?)
- Design enhanced scope of practice (?)
- Prepare training for HWs to enhance scope of practice (?)
- Deliver training for HWs to enhance scope of practice (?)
- Train supervisors to support enhanced scope (?)
- Other activities (?)
|
B2 Different Types of Health Workers
(?)
- Conduct stakeholder consultations regarding new cadres (?)
- Develop new cadre proposal and plan roll-out (?)
- Design training for new cadre (?)
- Conduct training to develop new cadre (government led training) (?)
- Provide support during education (at university or training center) (?)
- Training for supervisors to support new cadre (?)
- Other activities (?)
|
B3 Compulsory Service
(?)
- Develop compulsory service policy (?)
- Train mentors/supervisors (?)
- Provide support (housing, stipend, other) during compulsory service (?)
- Provide relocation support at end of service (?)
- Conduct compliance monitoring (?)
- Provide ongoing management of program (?)
- Other activities (?)
|
B4 Subsidized Education for Return of Service
(?)
- Design subsidized education policy (?)
- Provide tuition and other subsidies (?)
- Conduct compliance monitoring (?)
- Provide ongoing management of program (?)
- Other activities (?)
|
Financial Incentives (?) |
C1 Appropriate Financial Incentives
(?)
- Conduct HW research and consultations regarding financial incentives (?)
- Provide financial incentives (?)
- Other activities (?)
|
Professional And Personal Support (?) |
D1 Better Living Conditions
(?)
- Construct and furnish new staff housing (?)
- Upgrade electricity in existing accommodations (?)
- Provide water in existing accommodations (?)
- Improve telecommunications (?)
- Improve schooling for children (?)
- Conduct regular maintenance/repairs (?)
- Other activities (?)
|
D2 Safe and Supportive Working Environment
(?)
- Make structural repairs for health facilities (?)
- Upgrade/replace equipment in health facilities (?)
- Improve medicines and supplies (?)
- Train managers to be more supportive (?)
- Provide on-site supervision and support (?)
- Conduct regular maintenance/repairs (?)
- Provide Transportation Support (?)
- Other activities (?)
|
D3 Outreach Support
(?)
- Design Outreach Support Program (?)
- Support urban Health Workers to visit rural areas (?)
- Support rural Health Workers to visit urban areas (?)
- Provide grants to support telehealth networks (?)
- Provide ongoing management of program (?)
- Other activities (?)
|
D4 Career Development Programs
(?)
- Develop health worker career development plan or policy (?)
- Design education programs to support staff advancement (?)
- Conduct training to support staff advancement (?)
- Support Health Workers to attend existing training (?)
- Other activities (?)
|
D5 Professional Networks
(?)
- Provide grants to develop rural professional associations or rural health journals (?)
- Sponsor rural Health Worker conference (?)
- Provide grants to Health Workers to support networking (?)
- Other activities (?)
|
D6 Public Recognition
(?)
- Design program for Health Worker awards (?)
- Provide national awards to rural Health Workers (?)
- Provide grants to regions/districts to provide Health Workers awards (?)
- Sponsor rural Health Workers to attend international conferences (?)
- Support rural health days (?)
- Other activities (?)
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