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lobalpolicyr

ecommendati

ons

Increasing access

to health workers in

remote and rural areas

through improvedretention

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Increasing access to health workersin remote and rural areas throughimproved retention

Global policy recommendations

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All rights reserved. Publications o the World Health Organization can be obtained rom

WHO Library Cataloguing-in-Publication Data

Increasing access to health workers in remote and rural areas through improved retention:

global policy recommendations.

1.Health personnel. 2.Delivery o health care. 3.Rural health. 4.Rural health services.

I.World Health Organization.

ISBN 978 92 4 156401 4 (NLM classication: WA 390)

World Health Organization 2010

All rights reserved. Publications o the World Health Organization can be obtained rom

WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland

(tel.: +41 22 791 3264; ax: +41 22 791 4857; e-mail: [email protected]). Requests or

permission to reproduce or translate WHO publications whether or sale or or noncommercialdistribution should be addressed to WHO Press, at the above address (ax: +41 22 791 4806;

e-mail: [email protected]).

The designations employed and the presentation o the material in this publication do not imply

the expression o any opinion whatsoever on the part o the World Health Organization concerning

the legal status o any country, territory, city or area or o its authorities, or concerning the

delimitation o its rontiers or boundaries. Dotted lines on maps represent approximate border

lines or which there may not yet be ull agreement.

The mention o specic companies or o certain manuacturers products does not imply that

they are endorsed or recommended by the World Health Organization in preerence to others oa similar nature that are not mentioned. Errors and omissions excepted, the names o proprietary

products are distinguished by initial capital letters.

All reasonable precautions have been taken by the World Health Organization to veriy the inorma-

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warranty o any kind, either expressed or implied. The responsibility or the interpretation and use

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Printed in France

Graphic design : Atelier Rasmussen / CH 2010

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i

Preace

Hal the worlds people currently live in rural and remote areas. The problem is that most health

workers live and work in cities. This imbalance is common to almost all countries and poses a majorchallenge to the nationwide provision o health services. Its impact, however, is most severe in low

income countries. There are two reasons or this. One is that many o these countries already suer

rom acute shortages o health workers - in all areas. The other is that the proportion o the popula-

tion living in rural regions tends to be greater in poorer countries than in rich ones.

The World Health Organization (WHO) has thereore drawn up a comprehensive set o strategies

to help countries encourage health workers to live and work in remote and rural areas. These

include rening the ways students are selected and educated, as well as creating better working

and living conditions.

The rst step has been to establish what works, through a year-long process that has involved a

wide range o experts rom all regions o the world. The second is to share the results with thosewho need them, via the guidelines contained in this document. The third will be to implement

them, and to monitor and evaluate progress, and - critically - to act on the ndings o that

monitoring and evaluation.

The guidelines are a practical tool that all countries can use. As such, they complement the WHO

Global Code o Practice on the International Recruitment o Health Personnel, adopted by the

Sixty-third World Health Assembly in May 2010.

The Code oers a ramework to manage international migration over the medium to longer term.

The guidelines are a tool that can be used straight away to address one o the rst triggers to

internal and international migration - dissatisaction with living and working conditions in ruralareas.

Together, the code o practice and these new guidelines provide countries with instruments to

improve workorce distribution and enhance health services. Doing so will address a long-standing

problem, contribute to more equitable access to health care, and boost prospects or improving

maternal and child health and combating diseases such as AIDS, tuberculosis and malaria.

Margaret Chan

Director-General, WHO

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iv

Research gaps and research agenda: Ian Couper (University o Witwatersrand, South Arica), Gilles

Dussault (Instituto de Higiene e Medecina Tropical, Lisbon, Portugal), Marjolein Dieleman (Royal

Tropical Institute, the Netherlands), Steve Reid (University o Cape Town, South Arica).

The ollowing WHO sta were actively involved in the expert consultations meetings. From

WHOs regional oces: Walid Abubaker (WHO Regional Oce or the Eastern Mediterranean),

Magdalene Awases (WHO Regional Oce or Arica), Muzaherul Huq (WHO Regional Oce or

South-East Asia), Ezekiel Nukuro (WHO Regional Oce or the Western Pacic), Galina Perlieva

(WHO Regional Oce or Europe), Felix Rigoli (WHO Regional Oce or the Americas). From

WHO departments in Headquarters: Karin Bergstrom (Stop TB), Delanyo Dovlo (Health Systems

Governance and Service Delivery), Varatharajan Durairaj (Health Systems Financing).

The expert consultation meetings were ably co-chaired by Manuel M. Dayrit (HRH) and Charles

Normand (University o Dublin, Ireland). Any disagreements between the members o the expert

group were dealt with by consensus.

Methodological support or producing the GRADE evidence tables and the balance worksheetswas provided by Elie Akl (State University o New York at Bualo, Bualo, NY, USA). Eli Akl was

not involved in drating the recommendations.

Declaration o Interest: all participants to the consultation meetings signed a declaration o

interest. Ten participants declared interest in terms o receiving non-commercial nancial support

or research and consulting rom public bodies interested in retention o health workers. These

interests were not considered to be conficts or the purposes o participation in the guideline

development.

Peer review: The document was peer reviewed by Lincoln Chen (China Medical Board, USA),

Yann Bourgueil (Institut de recherche et de documentation en conomie de la sant, France),Christiane Wiskow (Independent Consultant, Switzerland) and Uta Lehmann (University o

Western Cape, South Arica). Comments by the peer-reviewers were sent electronically and these

were discussed at the nal ull expert meeting in February 2010. The WHO Secretariat then made

all the appropriate amendments.

Logistics support or the expert consultation meetings was provided by Valerie Novarina

meetings organization (HMR/HRH), Amel Chaouachi IT and web publishing (HRH), and Gillian

Weightman nancial management (HRH). Additional editorial support was provided by Ben

Fouquet (HMR/HRH).

Financial support or producing these recommendations was received rom the United States

Agency or International Development and the European Union, and is grateully acknowledged.The views expressed herein can in no way be taken to refect the ocial opinion o the United

States Agency or International Development or the European Union.

The ull list o members o the expert group and other participants to all the expert consultation

meetings is provided at the end o this document.

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1

Tables o contents

Preace i

Contributors and acknowledgments iii

Executive Summar 3

1. Introduction 7

1.1 Rationale 7

1.2 Objective 8

1.3 Target audience 8

1.4 Scope 9

1.4.1 Types o health workers targeted 9

1.4.2 Geographical areas covered 9

1.4.3 Categories o interventions covered 10

1.5 Process or ormulating the global recommendations 10

1.6 Dissemination process 11

1.7 Methodology 11

1.8 Structure o the report 11

2. Principles to guide the ormulation o national policies to improve retention o

health workers in remote and rural areas 13

2.1 Focus on health equity 13

2.2 Ensure rural retention policies are part o the national health plan 13

2.3 Understand the health workorce 14

2.4 Understand the wider context 14

2.5 Strengthen human resource management systems 15

2.6 Engage with all relevant stakeholders rom the beginning o the process 16

2.7 Get into the habit o evaluation and learning 16

3. Evidence-based recommendations to improve attraction, recruitment and retention

o health workers in remote and rural areas 17

3.1 Education 18

3.1.1 Get the right students 18

3.1.2 Train students closer to rural communities 19

3.1.3 Bring students to rural communities 21

3.1.4 Match curricula with rural health needs 21

3.1.5 Facilitate proessional development 22

3.2 Regulatory interventions 23

3.2.1 Create the conditions or rural health workers to do more 23

3.2.2 Train more health workers aster to meet rural health needs 24

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3.2.3 Make the most o compulsory service 25

3.2.4 Tie education subsidies to mandatory placements 26

3.3 Financial incentives 27

3.3.1 Make it worthwhile to move to a remote or rural area 283.4 Personal and proessional support 29

3.4.1 Pay attention to living conditions 30

3.4.2 Ensure the workplace is up to an acceptable standard 31

3.4.3 Foster interaction between urban and rural health workers 31

3.4.4 Design career ladders or rural health workers 32

3.4.5 Facilitate knowledge exchange 33

3.4.6 Raise the prole o rural health workers 34

4. Measuring results: how to select, implement and evaluate rural retention policies 35

4.1 Relevance: which interventions best respond to national priorities and the

expectations o health workers and rural communities? 36

4.2 Acceptability: which interventions are politically acceptable and have the most

stakeholder support? 36

4.3 Aordability: which interventions are aordable? 38

4.4 Eectiveness: have complementarities and potential unintended consequences

between various interventions been considered? 38

4.5 Impact: what indicators will be used to measure impact over time? 39

5. Research gaps and research agenda 42

5.1 Research gaps 42

5.1.1 Study all types o health workers 42

5.1.2 More research in low-income countries 42

5.1.3 More well-designed evaluations 42

5.1.4 Quality o the evidence not only what works, but also why and how 42

5.2 Research agenda 43

6. Deciding on the strength o the recommendations 44

Methodolog 62

List o participants 66

Reerences 69

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3

Executive Summary

Wh these recommendations?

Policy-makers in all countries, regardless o their level o economic development, struggle to

achieve health equity and to meet the health needs o their populations, especially vulnerable anddisadvantaged groups. One o their most complex challenges is ensuring people living in rural and

remote locations have access to trained health workers. Skilled and motivated health workers in

sucient numbers at the right place and at the right time are critical to deliver eective health

services and improve health outcomes. A shortage o qualied health workers in remote and rural

areas impedes access to health-care services or a signicant percentage o the population, slows

progress towards attaining the Millennium Development Goals and challenges the aspirations o

achieving health or all. The World Health Organization (WHO) has produced these recommenda-

tions in response to requests rom global leaders, civil society and Member States.

What is the scope?

The evidence-based recommendations relate to the movements o health workers within the

boundaries o a country and ocus solely on strategies to increase the availability o health workersin remote and rural areas through improved attraction, recruitment and retention. As such they

complement the current work o WHO on the Global Code o Practice on the International

Recruitment o Health Personnel (see Annex 3). The recommendations apply to all types o health

workers in the ormal, regulated health sector, including health managers and support sta, as

well as to students aspiring to or currently attending education programmes in health-related

disciplines.

What are the specic recommendations?

It is important to stress that there is much more helpul detail in the body o the report and that

the best results will be achieved by choosing and implementing a bundle o contextually relevant

recommendations.

A. EDUCATION RECOMMENDATIONS

1. Use targeted admission policies to enrol students with a rural background in education

programmes or various health disciplines, in order to increase the likelihood o graduates

choosing to practise in rural areas.

2. Locate health proessional schools, campuses and amily medicine residency programmes

outside o capitals and other major cities as graduates o these schools and programmes

are more likely to work in rural areas.

3. Expose undergraduate students o various health disciplines to rural community experiences

and clinical rotations as these can have a positive infuence on attracting and recruiting

health workers to rural areas.

4. Revise undergraduate and postgraduate curricula to include rural health topics so as to

enhance the competencies o health proessionals working in rural areas, and thereby

increase their job satisaction and retention.

5. Design continuing education and proessional development programmes that meet the

needs o rural health workers and that are accessible rom where they live and work, so as

to support their retention.

B. REGULATORY RECOMMENDATIONS

1. Introduce and regulate enhanced scopes o practice in rural and remote areas to increase

the potential or job satisaction, thereby assisting recruitment and retention.

2. Introduce dierent types o health workers with appropriate training and regulation or rural

practice in order to increase the number o health workers practising in rural and remote areas.

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3. Ensure compulsory service requirements in rural and remote areas are accompanied with

appropriate support and incentives so as to increase recruitment and subsequent retention

o health proessionals in these areas.

4. Provide scholarships, bursaries or other education subsidies with enorceable agreements o

return o service in rural or remote areas to increase recruitment o health workers in theseareas.

C. FINANCIAL INCENTIVES RECOMMENDATION

1. Use a combination o scally sustainable nancial incentives, such as hardship allowances,

grants or housing, ree transportation, paid vacations, etc., sucient enough to outweigh

the opportunity costs associated with working in rural areas, as perceived by health wor-

kers, to improve rural retention.

D. PERSONAL AND PROFESSIONAL SUPPORT RECOMMENDATIONS

1. Improve living conditions or health workers and their amilies and invest in inrastructure

and services (sanitation, electricity, telecommunications, schools, etc.), as these actors have

a signicant infuence on a health workers decision to locate to and remain in rural areas.

2. Provide a good and sae working environment, including appropriate equipment and

supplies, supportive supervision and mentoring, in order to make these posts proessionally

attractive and thereby increase the recruitment and retention o health workers in remote

and rural areas.

3. Identiy and implement appropriate outreach activities to acilitate cooperation between

health workers rom better served areas and those in underserved areas, and, where

easible, use telehealth to provide additional support to health workers in remote and rural

areas.

4. Develop and support career development programmes and provide senior posts in ruralareas so that health workers can move up the career path as a result o experience,

education and training, without necessarily leaving rural areas.

5. Support the development o proessional networks, rural health proessional associations,

rural health journals, etc., in order to improve the morale and status o rural providers and

reduce eelings o proessional isolation.

6. Adopt public recognition measures such as rural health days, awards and titles at local,

national and international levels to lit the prole o working in rural areas as these create

the conditions to improve intrinsic motivation and thereby contribute to the retention o

rural health workers.

What principles should guide the ormulation o national rural retention strategies?A number o interconnected principles should underpin all eorts to improve the recruitment and

retention o health workers in remote and rural areas. Adhering to the principle o health equit

will help in allocating available resources in a way that contributes to the reduction o avoidable

inequalities in health. And grounding rural retention policies in the national health plan will provide

a ramework or holding all partners accountable or producing tangible and measurable results.

The choice o interventions should be inormed by an in-depth understanding o the health

workorce. This requires, at a minimum, a comprehensive situation analysis, a labour market

analysis, and an analysis o the actors that infuence the decisions o health workers to relocate

to, stay in or leave rural and remote areas. Giving due consideration to the broader social,

economic and political actors at national, subnational and community levels that infuenceretention will help to ensure the choice o policy interventions are anchored in and tailored to the

specic context o each country.

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Assessing options and championing interventions to improve rural retention o health workers will

require human resource management expertise at the central and local levels, while implemen-

tation o the chosen policies will require individuals with strong management and leadership skills,

especially at the acility level. Engagement o stakeholders across several sectors is a critical

element or the success o rural retention policies, as it is or any type o health system or health

workorce policy. Rural and remote communities, proessional associations and other relevant

decision-makers must be included rom the beginning to obtain and maintain the support o

all involved.

A commitment to monitoring and evaluation and to operational research is essential in

order to evaluate eectiveness, revise polices as necessary once implementation is underway,

capture valuable lessons learnt, build the evidence base, and improve understanding about how

interventions work and why they work in some contexts but ail in others.

How to select and evaluate the interventions?

As in many areas o health systems policies, sound evaluations o rural retention interventions are

lacking. In order to support the needed paradigm shit towards more and better evaluations, thisreport proposes a ramework and ve questions to guide policy-makers in the selection, design,

implementation and monitoring and evaluation o appropriate rural retention interventions.

a) Relevance: which interventions best respond to national priorities and the expectations o

health workers and rural communities?

b) Acceptability: which interventions are politically acceptable and have the most stakeholder

support?

c) Aordability: which interventions are aordable?

d) Eectiveness: have complementarities and potential unintended consequences between

various interventions been considered?e) Impact: what indicators will be used to measure impact over time?

The ramework species the dimensions on which eects o retention strategies can be measured:

attractiveness, recruitment, retention and health workorce and health systems perormance.

One o the challenges in evaluation is that each recommendation has more than one outcome

(or eect), and no outcome can be achieved through only one intervention. This complexity adds

to the task o measuring the results and attributing the achieved eects to specic interventions.

How were the recommendations ormulated?

The WHO Secretariat convened a gender-balanced group o experts comprised o researchers,

policy-makers, unders, representatives o proessional associations and programme implemen-ters, drawn rom each o the WHO regions. The expert group was asked to examine existing

knowledge and evidence and to provide up-to-date, practical guidance to policy-makers on how

to design, implement and evaluate strategies to attract and retain health workers in rural and

remote areas.

The recommendations were developed ollowing a comprehensive review o all relevant and

available evidence related to health workorce attractiveness, recruitment and retention in remote

and rural areas. They have also been inormed by country experiences and judgements o the

experts, who met six times between February 2009 and February 2010. The expert group consi-

dered that in this eld it is equally important to understand whether an intervention works or not

(eectiveness) and also why it works and how. Context may be responsible or dierent outcomes

or results rom the same intervention and thus needs to be better captured in the research onthese interventions.

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All eorts were made to comply with standards or reporting, processing and using evidence in

the production o WHO guidelines as required by the Organizations Guidelines Review Committee

(GRC). This includes using a system or assessing evidence or interventions known as GRADE

(Grading o Recommendations Assessment, Development and Evaluation) and presenting the

quality o the evidence in the GRADE ormat. But, because o the richness o the inormation in

this eld, particularly with regard to the mechanisms that make interventions work, the expert

group decided to supplement the GRADE approach with additional evidence.

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

AnnexesonCD-ROMincludedetailsofalltheevidencethatwasusedindevelopingthe

recommendations (GRADE evidence proles, descriptive evidence tables).

SeveralpapersthatinformedthedevelopmentofthisreportwerepublishedinMay2010ina

special them issue o the Bulletin o the World Health Organization.

ThreecommissionedreviewshavebeenpublishedbyWHO:areviewoftheimpactofcom-

pulsory service on the recruitment and retention o health workers in rural areas; a realistic

evaluation that sought to understand not only whether certain interventions worked or not,

but also why and how; and a review o the role o outreach support on the recruitment o

health workers in remote and rural areas.

Aseriesofcomprehensivecountrycasestudiesarebeingpublishedincludingreportsfrom

Australia, China, Ethiopia, Lao Peoples Democratic Republic, Mali, Norway, Samoa, Senegal,

Vanuatu and Zambia.

Whats next?

The document is available in print, on the WHO website and on CD-ROM, and it will be circulated

through WHO channels or adaptation and implementation at country level. It will also betranslated and subsequently disseminated. Some countries, including the Lao Peoples Democratic

Republic and Mali, are already considering these recommendations to inorm the design o their

retention strategies, with the WHO Secretariat providing technical assistance, as required. In

addition, several members o the expert group are leading a research eort to ll some o the

evidence gaps that have emerged through the development o this document.

The recommendations are expected to remain valid until 2013. The Health Workorce Migration

and Retention Unit in the Department o Human Resources or Health at WHO headquarters in

Geneva will be responsible or initiating a revision o these global recommendations by that time,

based on new evidence and research and eedback rom countries that have been using the

recommendations. The possibility to expand the scope o the recommendations, or example, to

include recruitment and retention strategies or all underserved areas, shall also be considered.

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World Population* Nurses worldwide ** Phsicians worldwide **

1. Introduction

1.1 RationalePolicy-makers in all countries, regardless o their level o economic development, struggle to

achieve health equity and to meet the health needs o their populations, especially vulnerable anddisadvantaged groups. One o their most complex challenges is ensuring people living in rural and

remote locations have access to trained health workers. Skilled and motivated health workers in

sucient numbers at the right place and at the right time are critical to deliver eective health

services and improve health outcomes. Insucient numbers and types o qualied health workers

in remote and rural areas impedes access to health-care services or a signicant percentage o the

population, slows progress towards attaining the Millennium Development Goals and challenges

the aspirations o achieving health or all.

This is a global problem that aects almost all countries. Approximately one hal o the global

population lives in rural areas, but these areas are served by only 38% o the total nursing work-

orce and by less than a quarter o the total physician workorce (see Figure 1.1). The situation

is especially dire in 57 countries where a critical shortage o trained health workers means anestimated one billion people have no access to essential health-care services (1). In Bangladesh,

or example, 30% o nurses are located in our metropolitan districts where only 15% o the

population lives (2). In South Arica, 46% o the population lives in rural areas, but only 12% o

doctors and 19% o nurses are working there (3). To compound the problem, in some rancophone

sub-Saharan Arican countries, like Cte dIvoire, the Democratic Republic o the Congo and Mali,

the overproduction o health workers relative to the capacity or absorption has led to medical

unemployment in urban areas and shortages in rural areas (4).

Even high-income countries have shortages o health workers in remote and rural areas. In the

United States o America (USA), 9% o registered physicians practise in rural areas where 20% o

the population lives (5). France has large inequalities in the density o general practitioners, withhigher densities in the south and the capital compared with the centre and north o the country

(6). And in Canada, only 9.3% o physicians work in remote and rural areas where 24% o the

population lives (7).

Figure 1. Rural/urban worldwide distribution o phsicians and nurses

* Source: (18) ** Source: (1)

Every government infuences the health labour market through regulation, nancing and inorma-

tion. An entirely ree labour market will never lead to a well-distributed health workorce because

many people are drawn to urban centres or in some cases to other countries.

An abundance o evidence and experience shows that political commitment and policy interven-tions are central to more equitable health workorce distribution. In countries as diverse as China,

Cuba and Thailand, a variety o long-standing commitments towards the education, training and

specic support o rural health workers have led to improvements in the populations access to

committed health workers in these areas (8-10).

Rural50%

Urban50%

Rural38%

Urban62%

Rural24%

Urban76%

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However, no country has completely solved these challenges; hence several recent international

events have highlighted the importance o improving health worker retention and called or more

eective policy interventions (see Box 1).

Box 1. International calls to action TheWorldHealthAssemblyresolutionsonmigrationin2004andrapidscalingupof

health workers in 2006 both requested Member States put in place mechanisms to address

the retention o health workers.

InMarch2008,theKampala Declaration rom the First Global Forum o Human Resources

or Health requested governments to assure adequate incentives and an enabling and

sae working environment or eective retention and equitable distribution o the health

workorce.

TheG8CommuniquofJuly2008restatedtheneedtoassuretheeffectiveretentionof

health workers.

TheNovember2008reportfromtheCommissiononSocialDeterminantsofHealthurgedaction by governments and international partners to specically address the imbalances in

the geographical distribution o health workers in rural areas as a structural determinant

o poor health outcomes.

InJune2009thehigh-levelTaskforceonInnovativeInternationalFinancingforHealth

urged all governments to ensure that all people, including rural and remote populations,

have access to sae, high-quality and essential health-care services.

Sources:

http://www.who.int/gb/ebwha/pdf_les/WHA57/A57_R19-en.pdf

https://apps.who.int/gb/ebwha/pdf_les/WHA59/A59_R23-en.pdf

http://www.who.int/workforcealliance/Kampala%20Declaration%20and%20Agenda%20web%20le.%20FINAL.pdf

http://www.mofa.go.jp/policy/economy/summit/2008/doc/pdf/0708_09_en.pdf

http://www.who.int/social_determinants/thecommission/nalreport/en/index.html

http://www.internationalhealthpartnership.net/en/taskforce

1.2 ObjectiveThe World Health Organization (WHO) responded to calls to action rom global leaders, civil

society and Member States by convening a group o experts to examine existing knowledge

and evidence and to provide up-to-date, practical guidance to policy-makers on how to design,

implement and evaluate strategies to attract and retain health workers in rural and remote areas.

In doing so, these recommendations support countries in their eorts to improve health outcomesby strengthening the capacity o health systems to provide quality health care that is accessible,

responsive, eective, ecient and equitable.

1.3 Target audienceThis report emphasizes that sustained political, institutional and nancial commitments are

needed, as is the involvement o many dierent stakeholders. As such, this report is aimed at

government leaders and national policy-makers across several sectors including health, nance,

education, labour and public service. Stakeholders include health system managers, human

resource managers, heads o education and training institutions, employers o health workers,

proessional associations representing dierent cadres o health workers, civil society, nongovern-

mental organizations and remote and rural communities.

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1.4 ScopeThis is the rst time that global recommendations have been published on this important issue.

This report builds on work that has already been done in human resources or health, including

the Joint Learning Initiative Report (11), the World Health Report 2006 (1), and the report o the

Task Force on Scaling Up Education and Training o Health Workers (12). It draws on relevant

methods and tools, including the HRH Action Framework (13) and the Handbook on Monitoring

and Evaluation o Human Resources or Health (14).

The evidence-based recommendations relate to the movements o health workers within the

boundaries o a country, and complement the current work o WHO on the Global Code o

Practice on the International Recruitment o Health Personnel (see Annex 3), which aims to

address the challenges o international movements o health workers (15).

The recommendations ocus solely on strategies to increase the availability o motivated and

skilled health workers in remote and rural areas through improved attraction, recruitment and

retention o health workers in these areas. They become relevant once a country has assessed the

health needs o its population, has planned and projected the uture needs or health workers,and is at the point o considering strategies or their production, distribution and retention.

At the same time, a variety o other actors might impede peoples access to health services in

rural or remote areas, including socioeconomic deprivation, geographical barriers and distance,

transport, telecommunications, the cost o accessing services and the acceptability o services.

Eorts to address these actors may also infuence the availability o health workers in rural and

remote areas.

1.4.1 Types o health workers targetedThe recommendations apply to all types o health workers in the ormal, regulated health

sector (public and non-state), as well as to students aspiring to or currently attending educationprogrammes in health-related disciplines. This includes health-care providers (doctors, nurses,

midwives, mid-level health workers, pharmacists, dentists, lab technicians, community health

workers, etc.) as well as managers and support workers (human resource managers, health

managers, public health workers, epidemiologists, clinical engineers, teachers, trainers, etc.).

1.4.2 Geographical areas coveredThese recommendations are specically aimed at remote and rural areas as opposed to all

underserved areas. This is in part because their geographical situation requires specic interven-

tions and because addressing rural and remote areas will also address the needs o underserved

populations more broadly, but not vice versa.

Underserved areas are geographical areas where populations have limited access to qualiedhealth-care providers and quality health-care services. They include remote and rural areas, small

or remote islands, urban slums, confict and post-confict zones, reugee camps, minority and

indigenous communities, and any place that has been severely aected by a major natural or

man-made disaster. When the recommendations are revised the geographical scope could be

expanded to include other underserved areas, i deemed necessary by the expert group and

countries.

There are no precise universal denitions or urban areas and rural areas. According to the

United Nations, the distinction between urban and rural population is not amenable to a single

denition that would be applicable to all countries because o national dierences in the charac-

teristics that distinguish urban rom rural areas (16).

Each countrys own denition or these terms generally takes into account two main elements:

the settlement prole (population density, availability o economic structures) and the accessibi-

lity rom an urban area (distance in kilometres or hours drive).

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10

For the purpose o these recommendations, rural areas are areas that are not urban in nature (17).

An urban area usually incorporates the population in a city or town plus that in the suburban

areas lying outside o but being adjacent to the city boundaries (18).

1.4.3 Categories o interventions coveredAlthough there are other ways o increasing the access o populations living in remote and rural

areas to adequate health services, or example through dierent models o service delivery, or

through internationally recruited health workers, these recommendations ocus only on interven-

tions that are within the remit o human resources planning and management. The our main

categories o interventions are:

a) education

b) regulation

c) nancial incentives

d) personal and proessional support.

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

1.5 Process or ormulating the global recommendationsAn initial literature search was conducted by WHO in 2008, and a background paper was

prepared or the rst meeting o the expert group in February 2009. In selecting the members,

careul consideration was given to achieving a gender balanced group, with representation rom

all WHO regions and relevant constituencies (policy-makers, academics, unders, proessional

associations and rural health workers). Members o the expert group are listed on pages 6668.

The WHO background paper provides a comprehensive review o the current thinking and

evidence in this area and highlights signicant knowledge gaps (19). The experts used the

background paper to agree on the research questions to be addressed by this report, and on the

our categories o interventions. During their rst meeting, they also nalized a plan o action tourther supplement the evidence base, and some o the experts sel-selected into a core expert

group to undertake the additional systematic research needed. Subsequent expert consultations

(two o the core group in April and October 2009, and two o the ull expert group in June and

November 2009) discussed the results o the additional research and proposed drat recommen-

dations. During these consultations, members o the core expert group provided initial text or the

recommendations, which were subsequently revised by the WHO Secretariat (20).

The revised drat recommendations were presented to policy-makers, academics and other

stakeholders rom 15 Asian countries and eight Arican countries during a regional workshop

in November 2009 in Hanoi, Viet Nam (21). Participants had the opportunity to discuss their

experiences and challenges in improving rural and remote retention and to comment on the drat

recommendations.

The experts met or the nal time in February 2010 to discuss again the drat recommendations,

particularly with a view to rank the recommendations based on the quality o the evidence, benets,

values, and resource use. Balance worksheets were prepared or each recommendation, containing

the actors taken into account in ranking the recommendations. Follow-up was done by e-mail

with the core group on the nal evidence tables and on the revised balance worksheets or each

recommendation. The WHO Secretariat incorporated the experts inputs and nalized the report.

Several papers that inormed the development o this report were published in May 2010 in a

special theme issue o the Bulletin o the World Health Organization, a peer-reviewed journal

(22). In addition, two experts were commissioned to write reports on compulsory service schemesand outreach services in order to review and analyse available evidence related to these specic

recommendations. Another expert conducted a realist review o a selection o retention studies

with the aim o better understanding the infuence o contextual actors and the mechanisms

that make interventions work or ail. Comprehensive country case studies were also conducted in

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Australia, Ethiopia, the Lao Peoples Democratic Republic, Mali, Norway, Samoa, Senegal, Vanuatu

and Zambia in order to understand country specicities and to share lessons learnt. These reports

and country case studies were a signicant contribution to the evidence base or these recommen-

dations and will all be published as standalone documents and will be accessible online at: http://

www.who.int/hrh/resources/.

1.6 Dissemination processThe document will be printed and made available on the WHO web site, as well as on CD-ROM,

and will be circulated through WHO channels or adaptation and implementation at country

level. It will also be translated and subsequently disseminated. The recommendations given in this

document are expected to remain valid until 2013. The Health Workorce Migration and Retention

Unit in the Department o Human Resources or Health at WHO Headquarters in Geneva will be

responsible or initiating a review o these global recommendations at that time, based on new

evidence and research and eedback rom countries that have been using the recommendations.

The possibility to expand the scope o the recommendations, or example, to include recruitment

and retention strategies or all underserved areas, shall also be considered.

1.7 MethodologyThese recommendations were developed ollowing a comprehensive review o all relevant and

available evidence related to health workorce attractiveness, recruitment and retention in remote

and rural areas. Much o the evidence in this eld comes rom observational studies, rarely rom

well-designed cohort studies or beore-and-ater studies. Unlike clinical medicine, it is quite

dicult, i not impossible, to conduct randomized controlled trials to understand the eects

o many o the interventions proposed in this document. These are complex interventions with

multiple outcomes, and many conounders detract rom the design o the interventions, and

intervene during the implementation phase. The expert group considered that in this eld it is

equally important to understand whether an intervention works or not (eectiveness), and also

why it works and how. Context is a key element that can be responsible or dierent outcomes orresults rom the same intervention and thus needs to be better captured in the research on these

interventions.

All eorts were made to comply with standards or reporting, processing and using evidence in

the production o WHO guidelines as required by the Organizations Guidelines Review Committee

(GRC) (23). This includes using a system or assessing evidence or interventions known as GRADE

(Grading o Recommendations Assessment, Development and Evaluation) and presenting the

quality o the evidence in the GRADE ormat.

Because o the richness o the inormation in this eld, particularly with regard to the mechanisms

that make interventions work, the expert group elt that a considerable amount o valuable

evidence was not being captured by GRADE. As a result, early on in the process o ormulatingthese recommendations the experts decided to supplement the GRADE tables with an additional

table to ensure policy-makers had access to summaries o all relevant existing evidence. See

pages 62-65 or ull details about the methodology or the literature review, additional research,

evidence gathering and assessment.

1.8 Structure o the reportThis chapter provides the rationale and describes the process or the development o the global

recommendations on the retention o health workers in remote and rural areas. The remaining

ve chapters o the report address what should be done and why, based on an extensive literature

review, expert opinion and the consultative process:

theprinciplesandactionsthatshouldguidenationalstrategiestoimproveretentionofhealth

workers in remote and rural areas (Chapter 2)

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thespecicrecommendationsgroupedinfourmaincategories(Chapter3)

- education

- regulation

- nancial incentives

- personal and proessional support

howtoselectandevaluatetheinterventions(Chapter4)

theresearchagendaandactionplan(Chapter5)

detailsofthecriteriausedtorankeachoftherecommendationspresentedinChapter3

(Chapter 6).

The annexes, which are available on CD-ROM, as well as online, include details o the evidence

and inormation used in the ormulation o the recommendations:

theevidenceprolesfortherecommendationsA1A5,B1B3,C1andD1D6(Annex1)

acomprehensivetablecontainingdescriptiveevidencenotincludedintheevidenceproles

(Annex 2)

ResolutionWHA63.16andtheWHOGlobalCodeofPracticeontheInternationalRecruitment

o Health Personnel (Annex 3).

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Bounding ormandator

service

Financialaspects

Careerrelated

Workingand livingconditions

Famil andcommunit

aspects

Personalorigin and

values

Decision to re-locate to, sta

in or leaverural area

PersonalRural background (origin), values, altruism

Famil and communitProvision o schooling or children, sense ocommunity spirit, community acilities available

Financial aspectsBenets, allowances, salaries, payment system

Career relatedAccess to continuing education opportunities,

supervision, proessional development courses/workshops etc, senior posts in rural areas

Working and living conditionsInrastructure, working environment, access totechnology/medicines, housing conditions etc

Bonding or mandator service:Whether obligated to serve there

2.3 Understand the health workorceBeore embarking on any o the recommended interventions, a clear understanding o the health

workorce is necessary. This comprises an understanding o the current levels and distribution o

health workers by gender, geographical region, sector and speciality. A comprehensive situation

analysis and labour market analysis o current and uture needs o health workers should be able

to identiy any potential mismatches between supply and demand actors. For example, it can

identiy whether large numbers o unemployed health workers are located in urban areas, or

whether high remuneration dierentials exist between urban and rural areas, and thus can guide

appropriate interventions.

A detailed analysis o the actors that infuence the decisions o health workers to relocate to, stay

in or leave rural and remote areas is a key step in understanding the extent o the problem and in

guiding the appropriate choice o interventions. These actors are very complex, as they tend to

be related to personal aspects, health system characteristics and the overall social, economic and

political environment (see Figure 2). The interplay o these actors is also complex and strongly

infuenced by the underlying motivation, be this economic, social, cultural, religious, etc (26-28).

Figure 2. Factors related to decisions to relocate to, sta in or leave rural and remote areas

Source: adapted rom (29)

2.4 Understand the wider contextImproving the retention o health workers in remote and rural areas poses a number o complex

policy challenges that cannot be tackled within the health sector alone. Broader social, economic

and political actors at national, subnational and community levels that infuence retention also

need to be considered to ensure the choice o policy interventions are anchored in and tailored to

the specic context o each country.

Government and civil-service reorms can have positive or negative impacts o retention strategies.

For example, a broad public-sector reorm programme may strengthen systems or posting and

deployment across the public sector. But in Indonesia, one o the consequences o decentralization

has been the breakdown o the health personnel inormation system as decision-makers at the locallevel thought they were no longer obligated to send data to the upper level. This had consequences

on the regular payment o nancial incentives and the supervision o rural health workers (30).

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Making progress in raising education levels in rural and remote areas and prioritizing inrastructure

and services in rural areas (roads, water, sanitation, electricity, telecommunications, etc.) will both

improve peoples access to health services in remote and rural areas and make working in these

areas more attractive to health workers, as well as workers in other public sectors.

2.5 Strengthen human resource management systemsA core basic requirement or any retention strategy to be eective is management capacity.

Remote and rural retention strategies need to be grounded in human resource (HR) management

systems, which include key components such as workorce planning, recruitment and hiring

practices, work conditions, and perormance management, as well as competent HR managers

able to perorm these unctions (see Box 2).

HR management within the health sector in many countries is very weak, especially beyond the

central level, and this lack o capacity is a major barrier to rolling out successul human resources

or health (HRH) interventions. In addition, assessing options and championing interventions to

improve rural retention o health workers will require HR management expertise at the central

and local levels, while implementation o the chosen policies will require individuals with strongmanagement and leadership skills, especially at the acility level.

Organization capacity is also important, as is the continuity in the mechanism that provides the

oversight or implementing the recommendations: or example, sudden changes in administration

can result in unclear rules and procedures, which in turn can delay payments o allowances and

limit the interventions eectiveness.

Most countries will need to invest in proessional development programmes including training,

coaching, mentoring and proessional support or a strengthened HR management cadre and

capacity at all levels. Many countries will need to initiate or strengthen leadership development

programmes to improve supervision capacity in rural areas and create a supportive workplaceenvironment to attract and retain health workers. At the central level, HR managers and policy-

makers who can engage with stakeholders, analyse and understand their power and interests, and

negotiate compromises are crucial to the development o sustainable and easible HRH strategies,

including strategies to improve the retention o health workers in remote and rural areas.

Box 2. Elements o a strong HR management sstem

The key unctions o an eective HR management system are:

Personnel: workorce planning (including stang norms), recruitment, hiring and deployment

Work environment and conditions: employee relations, workplace saety, job satisactionand career development

HR inormation: data and inormation or decision-making

Perormance management: perormance appraisal, supervision and productivity.

The key component o a strong HR management system is proessionally prepared and compe-

tent HR managers who are able to perorm the HR unctions described below.

Workorce planning: Lead and support processes or eective HRH workorce planning based

on sound HR inormation; promote data-driven decisions; link HR proles and types o health

workers needed to achieve strategic health goals (e.g. decide about issues like task-shiting,

re-proling sta, redistribution, incentives, and so on); align workorce needs with HRH stra-

tegic plans; contribute to sound overall HRH strategic planning processes; and support goodcosting practices so that workorce projections can be budgeted appropriately.

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HR recruitment, hiring and deployment practices: Use their knowledge o eective prac-

tices in areas like recruitment and selection, orientation, deployment, sta development

and retention to promote positive change in the system by working with policy-makers to

identiy barriers to eective and ecient recruitment, hiring, deployment, retention, etc.

This work o promoting change also links to implementing things like task-shiting, incentivepackages, and so on.

Work environment and conditions: Monitor and support workorce environment practices

that contribute to high job satisaction, including eective employee relations, workplace

saety and career development.

HR inormation: Integrate inormation and data sources to ensure timely availability o accu-

rate data required or planning, training, appraising and supporting the workorce.

Perormance management, leadership and sta development: Ensure there is an eective

perormance appraisal system in place within the health system; lead and support systemic

productivity improvement interventions; use knowledge o up-to-date approaches to leadership

and management to promote good practices; assess the state o leadership and managementwithin the system, and organize or champion improvement programmes as needed; in general,

make sure health sta have the right competencies to do whatever they are required to do.

2.6 Engage with all relevant stakeholders rom the beginning o the processEngagement o stakeholders across several sectors is a critical element or the success o rural

retention policies, as it is or any type o health system or health workorce policy. In identiying

and selecting the most appropriate strategies a wide consultative and coordination eort is

needed. Rural and remote communities, proessional associations and other relevant decision-

makers must be included in the design, development, implementation, monitoring and evaluation

to obtain and maintain the support o all involved. Details about roles o various stakeholders inimplementing the proposed interventions are provided in Chapter 4.

2.7 Get into the habit o evaluation and learningA commitment to monitoring and evaluation rom the beginning is essential in order to capture

valuable lessons learnt and contribute to building the evidence base, which will be o use at

the country level and or countries that have similar contexts. Monitoring and evaluation will

help identiy challenges and limitations during implementation, assess the degree to which the

objectives and goals have been achieved, and identiy the need or a new intervention or the

need to re-design or modiy an existing one. Monitoring and evaluation should be part o the

design phase and integrated into the implementation plan (see Chapter 4). In addition, continuing

investment in national inormation systems is necessary to ensure timely and accurate data and

inormation are available to inorm the policy-making process.

Continuous learning is also critical. Applying so-called best practices rom one country to

another will not work without a clear understanding o the specic situation, needs and context.

Hence the need or operational research to evaluate eectiveness and revise polices as necessary

once implementation is under way. This will contribute to building the evidence base on why

interventions work in some contexts but ail in others, and how they work. This evidence will help

policy-makers in other countries choose the most appropriate interventions and to adapt them

as necessary to t their specic situation. The research gaps that were identied in the process o

developing each recommendation are mentioned in the tables in Chapter 6. In addition, details

about the quality o research in this eld and how it can be strengthened and supported are

provided in Chapter 5.

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3. Evidence-based recommendations to improve attraction,recruitment and retention o health workers in remote andrural areas

This chapter describes a range o interventions that can be combined to improve the retention o

health workers in remote and rural areas. The interventions all under our categories: education,

regulation, nancial incentives, and personal and proessional support (see Table 3.1 below).

Table1. Categories o interventions used to improve attraction, recruitment and retention

o health workers in remote and rural areas

Categor o intervention Examples

A. Education

A1 Students rom rural backgrounds

A2 Health proessional schools outside o major cities

A3 Clinical rotations in rural areas during studies

A4 Curricula that refect rural health issues

A5 Continuous proessional development or rural health workers

B. Regulator

B1 Enhanced scope o practice

B2 Dierent types o health workers

B3 Compulsory service

B4 Subsidized education or return o service

C. Financial incentives C1 Appropriate nancial incentives

D. Proessional andpersonal support

D1 Better living conditions

D2 Sae and supportive working environment

D3 Outreach support

D4 Career development programmes

D5 Proessional networks

D6 Public recognition measures

Each recommendation in this chapter is accompanied by a statement about the quality o the

evidence and the strength o the recommendation. These are requirements o GRADE (see section

1.7). As ar as the evidence is concerned, the majority o the studies in this eld are observational,

and most do not use a control group. GRADE considers this type o evidence to be o low quality.

Because o the certain limitations in using GRADE criteria to assess the quality o the evidence or

complex interventions with multiple outcomes, the expert group opted to give more weight to

other actors in deciding on the strength o the recommendations. These criteria include the balance

between benets and harms, the variability in values and preerences, the resources needed, and

technical easibility in dierent contexts. Balance worksheets were used by the expert group to pro-

vide details o these actors or each o the 16 recommendations, and they are presented in chapter

6. In general, when there was low quality o the evidence, the group considered more important the

values o equity and the dire need to give remote and rural populations access to health workers.

An intervention with a strong recommendation is associated with moderate or low quality

o the evidence in the GRADE tables, general consensus on the absolute magnitude o the eects

and benets, no signicant variability in how dierent stakeholders value the outcomes, andtechnical prerequisites or implementation that are easible in most settings. Interventions with a

strong recommendation are more likely to be successul in a wide variety o settings.

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A conditional recommendation or an intervention implies very low or low quality o the

evidence, only a small magnitude o eect over a short period o time, signicantly more poten-

tially negative eects, wide variability in values among stakeholders, and signicant variability

between countries in the prerequisites or implementation. A conditional recommendation is

less likely to be successul in all settings and requires careul consideration o the contextual issues

and the prerequisites or implementation, which are detailed in Chapters 2 and 4.

The current evidence and the experts knowledge, experience, opinions and judgements are

presented in this chapter in the evidence summaries and commentaries that accompany each

recommendation statement. The commentaries also highlight some o the major research gaps,

which are expanded on in Chapter 5. Further details can be ound in the tables in Chapter 6 and

in the annexes that are available on CD-ROM.

3.1 EducationEducation is the oundation or producing competent health workers. It is thereore important to

select the right students, that is, those who are more likely to practise in remote and rural areas,

and to train them in locations and using methods and curricula that are more likely to infuencetheir uture practice location. It is also important to support health workers need to continue

learning throughout their careers, particularly in isolated areas where access to knowledge and

inormation is not easy.

a1 Students rom rural backgrounds

a2 Health proessional schools outside o major cities

a3 Clinical rotations in rural areas during studies

a4 Curricula that refect rural health issues

a5 Continuous proessional development or rural health workers

3.1.1 Get the right students

recommendation a1

Use targeted admission policies to enrol students with a rural background in

education programmes or various health disciplines, in order to increase the

likelihood o graduates choosing to practice in rural areas.

Quality o the evidence moderate. Strength o the recommendation strong.

Summar o the evidence

There is a compelling body o evidence rom high-, middle- and low-income countries that a

rural background increases the chance o graduates returning to practise in rural communities.

Some studies have shown they continue to practise in those areas or at least 10 years (31-34).

A Cochrane systematic review states: It appears to be the single actor most strongly associated

with rural practice (35).

Several longitudinal studies tracking the practice locations o physicians in the USA have ound

that students with a rural background continue to practise in rural areas or an average o 1116

years ater graduation (see Box 3). In South Arica, students rom rural backgrounds are three

times more likely to practise in a rural location compared with their urban counterparts (32).

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Box 3. The Phsician Shortage Area Programme (PSAP) o Jeerson Medical College

A multiaceted education programme aimed at producing long-serving physicians or rural

areas in the USA has proven highly successul, according to the results o comprehensive

longitudinal cohort studies. Researchers tracked the location and retention o graduatephysicians rom the PSAP in rural areas o the USA or over 20 years. They ound that ater

11-16 years, 68% o the PSAP graduates were still practicing amily medicine in the same

rural area, compared with 46% o their non-PSAP peers. Although the PSAPs class sizes are

relatively small, the evidence indicates that a high percentage o its graduates serve in rural

areas or many years (33).

Commentar

Medical schools tend to have high education standards or admission. Countries with a lower level

o secondary education in rural areas compared with urban areas may need to link specic quotas

to admit students rom rural backgrounds with academic bridging programmes. China, Thailandand Viet Nam are a ew o the countries that have adopted this approach. The long-term solution

is or governments to improve the quality o primary and secondary education in remote and rural

areas.

Students rom rural areas may need more nancial assistance during their studies, as rural

amilies oten have signicantly lower incomes than urban amilies. They may also need more

academic and social support, because o the transition rom a rural to an urban area.

When students rom rural backgrounds are trained in schools also located in rural areas, using

curricula that are adapted or rural health needs, they are more likely to return to work in those

areas. Hence, it is important or policy-makers to bundle together at least these three interven-

tions or a better result (A1 bundled with A2 and A3, and with B4).

More research is needed to understand whether a certain prole o a uture rural health worker

can be identied: this may be related to geographical origin, gender, specic behaviour traits, such as

altruism, or other intrinsic motivation actors. Such knowledge would inorm selection and recruit-

ment policies, as well as counselling o high-school students prior to entering higher education.

There is inconclusive evidence about the extent to which gender and ethnicity are associated

with practising in rural areas. This needs urther research especially in countries where the

demography o the health workorce is rapidly changing as a result o many more women and

ethnic minorities entering medicine and nursing.

Little is known about preerential or targeted admissions o students rom rural backgrounds into

nursing or other health proessional schools.

3.1.2 Train students closer to rural communities

recommendation a2

Locate health proessional schools, campuses and amil medicine residenc

programmes outside o capitals and other major cities, as graduates o these

schools and programmes are more likel to work in rural areas.

Quality o the evidence low. Strength o the recommendation conditional.

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Large observational studies rom 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 ound that medical schools in the USA with the

ollowing characteristics tend to produce more rural physicians: located in rural states, public

ownership, oering training in generalist specialties and receiving little ederal research unding

(36). A study in the Democratic Republic o the Congo showed that location o a school in a

rural area was strongly associated with subsequent employment in the rural area (37). A study

in China showed that rural medical schools produce more rural physicians than medical schools

located in metropolitan centres (38). However, it is oten dicult to determine the independent

eect o rural location o schools, because research ndings tend to be conounded by such

actors as recruitment o more rural students in such schools (36). There is limited evidence that

graduates rom postgraduate residency programmes located in rural areas, particularly in amily

medicine, are also more likely to practise in a rural location, but there are some methodological

limitations or this evidence (39-41) (see Table 4.2).

CommentarComplementary 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 benets o locating schools or other health proessions in

rural areas in developing countries as well (4, 42),but the eects need to be better studied.

There is emerging evidence about the importance o promoting a social accountability ra-

mework or medical education in underserved areas to better respond to the needs o thesecommunities. For example, several need- and outcome-driven medicals schools in remote or

rural areas in Australia, Canada, the Philippines and South Arica ormed a network with a core

mission to increase the number, quality, retention and perormance o health proessionals in

underserved communities (http://www.thenetcommunity.org/). The principles o social accoun-

tability underpinning the training provided by these schools are highlighted in Box 4 below.

Box 4. Principles o social accountabilit underpinning the Training or Health

Equit Networks (THENet) medical schools

1. Health and social needs o targeted communities guide education, research and service

programmes.

2. Students are recruited rom the communities with the greatest health-care needs.

3. Programmes are located within or in close proximity to the communities they serve.

4. Much o the learning takes place in the community instead o predominantly in university

and hospital settings.

5. The curriculum integrates basic and clinical sciences with population health and social

sciences; and early clinical contact increases the relevance and value o theoretical learning.

6. Pedagogical methodologies are student-centred, problem- and service-based and sup-

ported by inormation technology.

7. Community-based practitioners are recruited and trained as teachers and mentors.

8. Schools partner with the health system to produce locally relevant competencies.

9. Faculty and programmes emphasize and model commitment to public service (43).

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3.1.3 Bring students to rural communities

recommendation a3

Expose undergraduate students o various health disciplines to rural communit

experiences and clinical rotations as these can have a positive infuence on attrac-ting and recruiting health workers to rural areas.

Quality o the evidence very low. Strength o the recommendation conditional.


Undergraduate training, particularly or physicians, is typically conducted in tertiary care insti-

tutions using the latest available technology and diagnostic tools. Once medical studies nish,

young graduates are let without skills to deal with health situations in areas where advanced

technology and tools are not available. The same holds true or other health proessions. Clinical

placements in rural areas during undergraduate studies is one way to expose students to the

health issues and conditions o service within rural communities, and give them a better unders-

tanding o the realities o rural health work.

The evidence on the eects o clinical rotations on improved retention is mixed, but it does show

that exposure to rural communities during undergraduate studies infuences subsequent choices

to practise in those areas, even or students with an urban background (44-47). These studies,

which were conducted or medical, pharmacy and nursing students, also show improved com-

petencies 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 some-

times the possibility that students rom a rural background may sel-select or these programmes,

bringing potential conounders to the results o the studies.

Commentar

Rural-based training may allow health workers to grow roots in such locations and acilitate

the development o proessional networks. It may also increase awareness o rural health, even

or those who may eventually choose not to practise in a rural area on a permanent basis. The

eect can be larger i this intervention is associated with A1 (targeted admission), A2 (location o

schools outside major cities) and A4 (changes in curricula).

The optimum duration o the rural exposure during undergraduate studies is not known. It varies

rom our weeks up to 36 weeks o placement, and it can be mandatory or voluntary. The local

availability o mentors, trainers and supervisors is a critical component o this intervention.

Stronger study designs are needed to better address conounders in sel-selection o studentsin the rural clinical placement programmes. More studies are needed on other types o health

workers and rom developing countries.

3.1.4 Match curricula with rural health needs

recommendation a4

Revise undergraduate and postgraduate curricula to include rural health topics so

as to enhance the competencies o health proessionals working in rural areas, and

thereb increase their job satisaction and retention.

Quality o the evidence low. Strength o the recommendation strong.

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Existing evidence in support o this recommendation is generally lacking, particularly in

developing countries and or disciplines other than medicine. However, there is evidence that

education with a primary care ocus or a generalist perspective is conducive to producing prac-

titioners willing and able to work in rural areas (48). 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, anaesthesia and surgery) can

enhance the condence o amily medicine residents and equip them with the requisite skills or

rural practice (49,50). This is because rural practitioners oten lack specialist support and have a

wider scope o practice.

Practising in rural areas is associated with three actors: a rural background; positive clinical and

educational experiences in rural settings during undergraduate education; and targeted training

or rural practice at the postgraduate level (51). However, the individual eects o each o these

actors on improved retention are dicult to estimate, because o many conounders. 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 compe-tencies necessary to practise in those areas (52). For example, a small-scale study in Australia was

able to show that when comparing mean percentages o th-year exam results, students rom

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

gynaecology, paediatrics, psychiatry and clinical examination (53).

Commentar

The practice o health workers in rural areas is quite dierent rom their urban counterparts, in

the way they need to conduct the clinical assessment and management without sophisticated

tools and equipment, and the way they need to collaborate with rural communities and manage

the rural context. Thereore, educating students in large teaching hospitals is unlikely to equipthem with the necessary skills and competencies to adequately address the health needs and

the conditions o practice in rural areas. Curriculum review and renewal on an ongoing basis

are needed, though the process can be time consuming. It is also important to ensure that the

rural context is refected in educational content. In addition, generalist or primary care ocused

curricula should include sucient exposure to relevant specialist knowledge in order to prepare

practitioners with a wider scope o practice that is oten required in rural areas. More studies

are needed on the direct eects o curricula changes on the retention o health workers, and

particularly in relation to non-physicians.

3.1.5 Facilitate proessional development

recommendation a5

Design continuing education and proessional development programmes that meet

the needs o rural health workers and that are accessible rom where the live and

work, so as to support their retention.



Access to continuing education and proessional development is necessary to maintain compe-tence and improve perormance o health workers everywhere (1). However, it may be dicult

or health workers in rural areas to access these programmes i it requires travelling to urban

locations. There is limited direct evidence on the eect o continuing education programmes on

retention. But there is ample supportive evidence that i delivered in rural areas, and i ocused

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on the expressed needs o rural health workers, these programmes are likely to improve the

competence o rural health workers, make them eel like they are a part o a proessional group,

and increase their desire to remain and practise in those areas (54-55).

Commentar

As or the previous interventions, better results are more likely with a combination o interven-

tions. To be successul, continuing education needs to be linked to career paths (D4), as well

as with other education interventions. Continuing education should be viewed rom a broader

perspective. Such activities are not only or knowledge acquisition or skills development, they

also provide opportunities or rural health workers to interact with other practitioners and to

maintain proessional networks and social contacts, which may help reduce the sense o social

or proessional isolation (56). Distance learning by means o inormation and communication

technologies should be used, where appropriate and available, in order to bring continuing

education programmes to more remote locations.

3.2 Regulatory interventionsRegulatory measures can be dened broadly to encompass any government control exercised

through legislative, administrative, legal or policy tools. Regulatory measures range rom parlia-

mentary laws/statutes to state regulations, policies and guidelines developed by line ministries, and

programme guidance. With regard to recruitment and retention in rural areas, the interventions that

require regulatory measures are related to expanding the scope o practice o rural health workers,

producing dierent types o health workers, compulsory service requirements and bonding

schemes.

b1 Enhanced scope o practice

b2

Dierent tpes o health workersb3 Compulsor service

b4 Subsidized education or return o service

3.2.1 Create the conditions or rural health workers to do more

recommendation b1

Introduce and regulate enhanced scopes o practice in rural and remote areas to in-

crease the potential or job satisaction, thereb assisting recruitment and retention.

Quality o the evidence very low. Strength o the recommendation conditional.


Health workers serving rural and remote communities may oten have to provide services beyond

the remit o their ormal training, because o the absence o other more qualied health wor-

kers. In some instances this de acto enhanced scope o practice is recognized through regulatory

measures (decrees, etc.) that allow certain categories o health workers to provide tasks that

are beyond their training, on the assumption that this will increase access to health services or

remote and rural populations.

Whether or not this expanded scope o practice has actually contributed to retention o healthworkers is unclear rom the current evidence. There is however evidence to show that enhanced

scope o practice can lead to increased job satisaction. For example, a control study in Australia

ound that enrolled nurses who were allowed to prescribe reported higher levels o job satisac-

tion than non-medication endorsed nurses (57).

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There is also compelling evidence that quality o care is not diminished when delivered by

health workers with enhanced scope o practice. Indeed, one systematic review (58)ound six

randomized controlled trials showing that quality o care was in some ways better or nurse

practitioner consultations when compared with physicians, although in non-rural settings. In

addition, patients reported higher levels o satisaction with nurse practitioners.

Commentar

Health workers with an enhanced scope o practice can provide vital health-service delivery

particularly in areas with an absolute shortage o health workers. For example, while eorts are

made towards scaling-up the production o physicians, nurse practitioners and mid-level workers

can be used to provide some o the services in the absence o physicians.

Ministries o health need to work with regulatory bodies, proessional associations and other

stakeholders in order to clearly stipulate the boundaries and guidelines or expanded scopes o

practices. There may be considerable resistance rom certain groups o health workers, and their

concerns and arguments need to be voiced and careully considered as part o this process.

B1 is oten bundled with B2 (dierent types o health workers). Combining this recommendationwith D6 will help ensure that all those working with an expanded scope o practice are reco-

gnized or the contribution and service they are delivering in remote and rural areas. Finally, the

attractiveness o relocating to a remote and rural area is likely to increase i the post includes

access to urther education and training (A5) and nancial incentives (C1).

While it has been acknowledged that health workers with enhanced scopes o practice can

contribute eectively 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 o package that is required to recruit and retain

health workers with enhanced scopes o practice.

3.2.2 Train more health workers aster to meet rural health needs

recommendation b2

Introduce dierent tpes o health workers with appropriate training and

regulation or rural practice in order to increase the number o health workers

practising in rural and remote areas.


Summar o the evidenceDierent types o 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 o sub-Saharan Arican

countries ound non-physician clinicians were active in 25 out o 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 o health workorces (59).

Box 5 highlights the ndings rom one o the ew studies investigating the retention o such

workers (60). Yet there is convincing evidence to support the act that dierent types o health

workers can lead to improved health outcomes (61) and that many countries heavily rely on

clinical ocers, health assistants and other types o health workers to provide health care in

remote and rural areas (62).

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Box 5. Tcnicos de cirurgia in Mozambique

Mozambique began to educate and train assistant medical ocers with surgical skills

called tcnicos de cirurgia in 1987. Twenty years later, a study ound that 88% o all the

tcnicos who graduated in 1987, 1988 and 1996 were still working in district hospitals,compared with only 7% o medical ocers who were originally assigned to district hospitals

ater graduation. Considering that these tcnicos perorm 92% o all major obstetrical

surgical interventions in rural hospitals, the authors argue that provision o emergency

obstetric care in these areas would be impossible without them (60).

Commentar

One rationale behind creating dierent cadres o health workers or remote and rural areas is

that their skills and qualications may be less marketable than those o highly-trained health

workers, who are also in demand in urban settings, or even outside the country. Another reason

or embracing this policy is that specic types o health workers can be trained to be morereceptive and reactive to local health needs, provided that quality and saety issues are also taken

into account (63). In addition, types o health workers that can be trained in a relatively short

period o time may be a more nancially viable option in low-resource settings. For increased

recruitment and retention, it is important to consider the use o nancial incentives (C1) and

recognition measures or these cadres (D6).

Although dierent types o 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 actors motivating mid-level cadres in comparison with higher-

trained health workers.

3.2.3 Make the most o compulsory service

recommendation b3

Ensure compulsor service requirements in rural and remote areas are accompanied

with appropriate support and incentives so as to increase recruitment and

subsequent retention o health proessionals in these areas.



Compulsory service is understood as the mandatory deployment o health workers in remote

or rural areas or a certain period o time, with the aim to ensure availability o services in these

areas. It can be either imposed by the government (or positions that are under government

employment), or linked to various other policies. For example, it can be a mandatory requirement

to serve or a certain period o time in remote areas beore obtaining the license to practise; or it

can be a prerequisite beore applying or a specialization or or career advancement.

A comprehensive review o compulsory service schemes undertaken as part o the development

o these recommendations ound that approximately 70 countries have previously used or are

currently using compulsory service (64). The duration varies rom country to country, rom aminimum o one year to a maximum o nine years, and the policies have included almost all

types o health workers.

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Despite the popularity o compulsory service, very ew evaluations have been conducted in relation

to the retention o health workers either during or post their obligated service period. Studies in

Ecuador (65) and South Arica (66) reveal that although physicians raised serious complaints over

the management o their compulsory service scheme, they did eel that the experience improved

their competencies and had been rewarding overall. In some countries, remote and rural areas are

reliant upon graduates who are comply

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