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