Manuel M Dayrit; Carmen Dolea*; Jean-Marc Braichet
Department of Human Resources for Health, World Health Organization, 20 avenue Appia, 1211 Geneva 27, Switzerland
This special theme issue of the Bulletin of the World Health Organization focuses on retention of health workers in rural and remote areas. Globally, half of the population lives in rural areas but they are only served by less than a quarter of all doctors and less than a third of all nurses. Therefore, providing people in rural areas with access to well trained health workers is a global challenge. It is critically important to succeed in this, particularly in the 57 low- and middle-income countries that are already plagued with critical shortages of health workers.1
The cover of The world health report 2006 shows a Ghanaian doctor, working in a remote health post in his country. He is smiling as he ministers to a sick, undernourished child. This is a poignant portrait of a hero, serving in a remote rural area, smiling as he goes about his duties. But the truth is that, while we may still have heroes who unselfishly opt to serve in poor areas, there are fewer and fewer of them who stay to do so. The majority of health workers migrate from the rural areas to the cities; and more and more leave poor countries for more attractive jobs abroad. While countries continue to rely on extraordinary individuals to care for their poor populations, they must make it easier for these heroes to thrive as they serve in remote and rural areas. Otherwise, the shortages in these areas will never be solved.
In response to this, the World Health Organization (WHO) has established a programme of work to "increase access to health workers in remote and rural areas through improved retention",2 with three strategic pillars: (i) building the evidence; (ii) developing policy recommendations from the evidence; and then (iii) supporting countries in implementing the recommendations and evaluating their impact. This special theme issue is part of the research efforts to harvest the current knowledge on this critical matter.3 The evidence-based recommendations, which are the first of its kind, were produced with the support of a large international group of experts and policy-makers. They will be officially issued in July 2010 but some of the papers presented in this issue have come out of the year-long consultative effort.4 - 9
The key messages illustrated by papers in this issue and also reinforced by the WHO expert group are as follows:
There is no one single-bullet solution to this problem. Interventions in education, regulation, financial incentives and personal and professional support all have the potential to provide a part of the solution. A "pipeline-to-practice" approach to education for rural practice seems promising, particularly if medical schools embrace a social accountability framework to make them more responsible to communities.10 Compulsory service as a method for rural recruitment is widely used but rarely evaluated.4 Contracting systems are explored by some countries such as Senegal,7 while others focus on professional development to reduce feelings of isolation, as in Norway. 8
Rural retention strategies must be applied in mutually reinforcing combinations or "bundles". They also take a relatively long time to yield results. Chile's Rural Practitioner Programme is a case in point. Peña et al. present an assessment of a five-decade programme, which linked financial incentives with education opportunities and personal support strategies to increase the recruitment and retention of physicians in rural areas in Chile.11
Effective retention strategies must respond to both the needs of the population and the expectations of health workers. Understanding the preferences of health workers for working in a rural area is essential in developing appropriate strategies. Three research papers in this issue present the findings of "discrete choice experiments" used to elicit preferences of either students or health workers for rural work.12 - 14 Contingency valuation methods such as these are increasingly used by researchers in this field as they have the potential to be a powerful tool for policy-makers in guiding the choice of most appropriate interventions.
Monitoring and evaluation should be built into the design and implementation of rural retention interventions. Challenges to conduct evaluations in this field, as in many others in health systems, are notorious. Acknowledging these challenges, Huicho et al. propose a conceptual framework to guide policymakers in monitoring and evaluation of rural retention interventions, with four dimensions, clear indicators and key questions.5 Building on that framework, Dolea et al. provide an extensive review of existing evaluations of rural retention strategies and identify the gaps in evaluative research in this field.6
Context matters and external factors influence to a great extent the success or failure of rural retention strategies. In a perspective, Haji et al. explore the potential of decentralization to lead to better health workforce recruitment, performanceandretention in ruralareas through the creation of additional revenue for the health sector and better use of existing financial resources.9
These efforts are only a part of WHO's broaderapproachtoaddressing health workforce development. Work is being done on developing a global code on the international recruitment of health personnel that will be deliberated on in the 63rd World Health Assembly this year. It is linked to the work to scale up the education and production of the various categories of health workers and it is informed by work to build the strategic information needed to improve governance of the health workforce, both globally and in countries.
Available at: http://www.who.int/bulletin/volumes/88/5/10-078485
1. The world health report 2006: working together for health. Geneva: World Health Organization; 2006.
2. WHO global recommendations for the retention of health workers[Internet site]. Geneva: World Health Organization. Available from: http://www.who.int/hrh/migration/retention/en/index.html [accessed 8 April 2010] .
3. Dolea C, Braichet JM, Shaw D. Health workforce retention in remote and rural areas: call for papers. Bull World Health Organ 2009;87:486-486. doi: 10.2471/BLT.09.068494
4. Frehywot S, Mullan F, Payne PW, Ross H. Compulsory service programmes for recruiting health workers in remote and rural areas: do they work? Bull World Health Organ 2010;88:364-370.
5. Huicho L, Dieleman M, Campbell J, Codjia L, Balabanova D, Dussault G et al. Increasing access to health workers in underserved areas: a conceptual framework for measuring results. Bull World Health Organ 2010;88:357- 363.
6. Dolea C, Stormont L, Braichet JM. Evaluated strategies to increase attraction and retention of health workers in remote and rural areas. Bull World Health Organ 2010;88:379-385.
7. Zurn P, Codjia L, Sall FL, Braichet JM. How to recruit and retain health workers in underserved areas: the Senegalese experience. Bull World Health Organ 2010;88:386-389.
8. Straume K, Shaw DMP. Effective retention strategies in Norway's northernmost county. Bull World Health Organ 2010;88:390-394.
9. Haji M, Varatharajan D, Zurn P, Stormont L, Mapunda M. Emerging opportunities for recruiting and retaining a rural health workforce through decentralized health financing systems. Bull World Health Organ 2010;88:397-399.
10. Rourke J. How can medical schools contribute to the education, recruitment and retention of rural physicians in their region? Bull World Health Organ 2010;88:395-396.
11. Peña S, Ramirez J, Becerra C, Carabantes J, Arteaga O. The Chilean Rural Practitioner Programme: a multidimensional strategy to attract and retain doctors in rural areas. Bull World Health Organ 2010;88:371-378.
12. Blaauw D, Erasmus E, Pagaiya N,TangcharoensatheinV, Mullei K, Mudhune S et al. Policy interventions that attract nurses to rural areas: a multicountry discrete choice experiment. Bull World Health Organ 2010;88:350-356.
13. Kruk ME, Johnson JC, Gyakobo M, Agyei-Baffour P, Asabir K, Kotha SR et al. Rural practice preferences among medical students in Ghana: a discrete choice experiment. Bull World Health Organ 2010;88:333-341.
14. Serneels P, Montalvo JG, Pettersson G, Lievens T, Butera JD, Kidanu A. Who wants to work in a rural health post? The role of intrinsic motivation, rural background and faith-based institutions in Ethiopia and Rwanda. Bull World Health Organ 2010;88:342-349.