EDITORIALS
Health workforce retention in remote and rural areas: call for papers
Carmen Dolea Jean-Marc Braichet*; Daniel MP Shaw
World Health Organization, 20 avenue Appia, 1211 Geneva 27, Switzerland
Although approximately one half of the global population lives in rural areas, these people are served by only 38% of the total nursing workforce and by less than a quarter of the total physicians' workforce. At the country level, imbalances in the distribution of health workers are even more prominent, in both developed and developing countries.1,2 Without local access to well trained and motivated health workers, it is unlikely that communities will have access to important primary health care services to respond to priority health needs and to achieve the Millennium Development Goals.3-5
Health workers have always tended to move in search of better living and working conditions, improved salaries and opportunities for professional development, be it within their own country, from rural to urban areas, or from public to private sector; or from one country to another.6 The effect of these movements can be devastating in countries or settings where there is an absolute shortage of health workers.4 Moreover, when developed countries recruit health workers from developing countries to fill vacant positions in their own rural areas, the situation is exacerbated.7
While the international recruitment of health workers can be addressed through non-binding legal instruments, such as codes of practice or bilateral agreements, for the intra-country migration of health workers there are other types of policy instruments that countries can use to retain health workers where they are most needed. Several calls for action have further highlighted the importance of this issue and the necessity to address the inequitable distribution of health workers within countries.2,6-9
In this context, WHO has recently launched a programme of work to support countries to increase access to health workers in remote and rural areas through improved retention.10 The programme consists of three strategic pillars: building the evidence base, supporting countries to implement and evaluate effective strategies, and producing evidence-based recommendations to improve retention of health workers in remote and rural areas. An important part of this programme is the work on expanding the knowledge base and the evidence on effective strategies and policies that countries can use to address the issue of inequitable distribution of health workers in remote and rural areas.
Much is known already about the factors that influence health workers' choices of location and their decisions to go to, stay in or leave these areas.8,11-13 However, there is very little evidence on specific operational solutions and recommendations that countries can adapt to their specific context in responding to this challenge; in particular evidence is lacking on the design, implementation and evaluation of these strategies.9
Broadly speaking, countries have put in place four main types of strategies to address this issue: educational interventions, such as the "rural pipeline" (targeted recruitment from rural areas), or continuous professional development support; regulatory interventions, such as loan repayment schemes, compulsory service requirements; financial incentives, such as salary increases, or different types of allowances; and interventions that address the working and living environment, such as supportive supervision, improved human resources management systems, reducing social isolation through tele-health, professional networks and wider rural development schemes.10
Often the various retention schemes are proposed without a baseline study to understand the factors that influence health workers' decisions to go to, stay in or leave remote or rural areas. Sustainability is another critical element that needs to be considered, both from a financial and a time perspective. Many interventions start as pilot experiments in a region or district, frequently driven by specific donor initiatives, with little capacity for scaling up or for sustaining the interventions for the longer term. The most effective interventions do not work in isolation, hence the need for a combined or "bundled" approach that addresses the multiple aspects of education, recruitment and management. And finally, evaluations of impact and effectiveness of different strategies are still lacking.
In this context, authors are invited to submit articles as a contribution to a special theme issue that will explore the challenges of health worker retention in remote and rural areas. Papers should aim at filling the gaps in the current knowledge on costs of implementing rural retention strategies and incentive schemes, and the extent to which context influences the design, implementation and the impact of various strategies. Innovative methodological papers that examine the monitoring and impact evaluation of various strategies are also encouraged, in particular with a view to understanding the long-term effects and sustainability of retention strategies.
Manuscripts on any of the above topics should be submitted to: http://submit.bwho.org by 1 October 2009. 
References
Available at: http://www.who.int/bulletin/volumes/87/7/09-068494/en/index.html
References
1. Zurn P, Dal Poz M, Stilwell B, Adams O. Imbalance in the health workforce. Hum Resour Health 2004;2:13. PMID:15377382 doi:10.1186/1478-4491- 2-13
2. Dussault G, Franceschini MC. Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce. Hum Resour Health 2006;4:12. PMID:16729892 doi:10.1186/1478-4491-4-12
3. Travis P, Bennett S, Haines A, Pang T, Bhutta Z, Hyder AA et al. Overcoming health-systems constraints to achieve the Millennium Development Goals. Lancet 2004;364:900-6. PMID:15351199 doi:10.1016/S0140- 6736(04)16987-0
4. The world health report 2006: working together for health. Geneva: World Health Organization; 2006.
5. The world health report 2008: primary health care now more than ever. Geneva: World Health Organization; 2008.
6. Awases M, Nyoni J, Gbary A, Chatora R. Migration of health professionals in six countries: a synthesis report. Brazzaville: World Health Organization Regional Office for Africa; 2003.
7. Audas R, Ryan A, Vardy D. The use of provisionally licensed international medical graduates in Canada. CMAJ 2005;173:1315-6. PMID:16301695
8. Dieleman M, Cuong PV, Anh LV, Martineau T. Identifying factors for job motivation of rural health workers in North Viet Nam. Hum Resour Health 2003;1:10. PMID:14613527 doi:10.1186/1478-4491-1-10
9. Dolea C. Stormont L, Shaw D, Zurn P, Braichet JM. Increasing access to health workers in remote and rural areas through improved retention.
10. Geneva: World Health Organization; 2009. Available from: http://www.who.int/hrh/migration/background_paper.pdf [accessed on 12 June 2009] .
11. Grobler L, Marais BJ, Mabunda SA, Marindi PN, Reuter H, Volmink J. Interventions for increasing the proportion of health professionals practicing in underserved communities. Cochrane Database Syst Rev 2009; 21;CD005314 10.1002/14651858.CD005314.pub2. PMID:19160251
12. Hongoro C, Normand C. Health workers: building and motivating the workforce In: Disease control priorities in developing countries. 2nd edn. New York, NY, Oxford University Press;2006.
13. Lehmann U, Dieleman M, Martineau T. Staffing remote rural areas in middle- and low-income countries: A literature review of attraction and retention. BMC Health Serv Res 2008;8:19. PMID:18215313 doi:10.1186/1472-6963-8-19
14. Mangham LJ, Hanson K. Employment preferences of public sector nurses in Malawi: results from a discrete choice experiment. Trop Med Int Health 2008;13:1433-41. PMID:18983274 doi:10.1111/j.1365- 3156.2008.02167.x
* Correspondence to Carmen Dolea (e-mail: doleac@who.int).