Retain Health Workers Research Articles

Incentives to attract and retain physicians to underserved areas - a case study from Portugal

Abstract Issue Physician shortages in underserved areas are a common challenge for governments and policymakers worldwide, including in Europe. Meanwhile, a knowledge gap exists on effective measures to address the issue. Description According to WHO Europe, one of ten actions to strengthen the healthcare workforce is to develop strategies to attract and retain health workers in rural and remote areas. Portugal faces geographical asymmetries in the distribution of physicians, and difficulties in retaining them in certain areas of the country. This case study seeks to describe and analyse the impact of an incentives package introduced in 2015 that aimed to attract and retain physicians in underserved areas. Financial incentives data was gathered via a national health human resources information system. Non-financial incentives data was reported by health institutions through an online form. Document analysis was conducted to understand the scope of the incentives package and its amendments. Results The incentives package implemented in Portugal effectively deployed physicians to underserved areas, since it led to a fourteen-fold increase in physicians settling in underserved areas. In terms of retention, an average of 59% of the physicians that took up the incentives package are still practicing in the same underserved area. However, the difference between the retention levels of physicians under the incentives package and those not covered is minimal. To further reduce health inequities and achieve universal health coverage, a need exists to review the financial and non-financial incentives to better suit physicians’ needs and expectations, as well as those of the National Health Service. Lessons The incentives package introduced in Portugal makes it clear that flexibility in the design of attraction and retention measures is crucial. It requires a long-term commitment and a recognition that each intervention should be assessed and adapted to local circumstances and context. Key messages • The incentives package introduced in Portugal attracted physicians to underserved areas and led to a fourteen-fold increase in physicians settling in underserved areas. • More than half of the physicians are still practicing in the same underserved health institution but the difference in retention against those not covered by the incentives package is minimal.

МЕДИЦИНСКИЕ ОРГАНИЗАЦИИ И ИХ СТРУКТУРНЫЕ ПОДРАЗДЕЛЕНИЯ, РАСПОЛОЖЕННЫЕ В СЕЛЬСКОЙ МЕСТНОСТИ

Significance. Provision of equal access to health care regardless of the patient's place of residence is a priority direction of the healthcare development. Identification of problems and development of organizational activities to develop medical infrastructure in rural areas are being currently prioritized. As many researchers note, the recent transformations of the healthcare system failed to yield the expected results in rural areas, including to attract and retain health workers. It should be pointed out that issues related to care access in rural areas are also associated with factors that are less dependable upon the healthcare system, namely, ensuring transport accessibility and increasing the socio-economic level of rural life. The presence of these factors requires a special approach to solving problems characteristic of rural areas. In this regard, it is highly relevant to study the provision of rural areas with a network of medical organizations, units, as well as basic resources. The purpose of the study was to conduct a retrospective analysis of medical infrastructure (medical organizations and their structural units) and available basic resources in rural areas in 2016 - 2022. Material and methods. The study used statistical materials “Rural Health Care in Russia” of the Ministry of Health of the Russian Federation and Federal Research Institute for Health Organization and Informatics of the Ministry of Health of the Russian Federation in 2016–2022, prepared using the Medstat program and data extraction from federal statistical observation form No. 30 “Information about a medical organization” on doctor staffing level of medical organizations in the Russian Federation, federal districts and constituent entities of the Russian Federation in 2016-2022. Four constituent entities of the Russian Federation (Donetsk and Lugansk People's Republics, Kherson and Zaporozhye regions) were not included in the analysis. The study used analytical and statistical methods. Descriptive statistics was conducted using the software package Statistica version 13.3. Results. Organization and development of the network of medical organizations in rural areas is carried out with due regard to regional peculiarities. The analysis shows that the infrastructure of medical organizations and their structural subdivisions located in rural areas is being developed due to mobile forms of work, set up of a network of rural outpatient clinics and increasing capacity of polyclinics. Conclusion. The study shows that organization of a network of medical organizations in rural areas has its own peculiarities: specific subdivisions and forms of work of medical specialists are being developed. In Russia, over the last seven years, due to reorganization (consolidation) of the network, the number of independent medical organizations has decreased by 16.2% with an active introduction of mobile forms of work. During the period under study, the number of medical outpatient clinics increased by 10.7%, mobile paramedical and midwifery station and health posts - almost 10-fold and mobile medical teams - by 15.5%. Another important positive aspect is the increase in the planned capacity of outpatient and polyclinic units in rural areas. The established trends suggest a higher access to medical care for rural dwellers. Negative trends have been identified as well: from 2016 to 2022, bed capacity decreased by 9.7%, and the share of buildings in emergency condition and subject to demolition increased from 1.28 to 3.88% or by 2.6 p.p. Scope of application. The study results may be of interest to health administrators, practicing physicians, residents and graduate students of medical universities.

Job preferences of Chinese primary health care workers: A discrete choice experiment.

Primary health workers (PHWs) are a critical pillar of health systems but primary health care centers often struggle to attract and retain talented staff. To better understand why this is, we investigated the job preference of PHWs in a Chinese urban setting. In a discrete choice experiment, PHWs from 15 primary health care centers in Guangzhou, China, made trade-offs between several hypothetical job scenario combinations of salary, type of health institution, bianzhi (permanent post), work years required for promotion, career development and training opportunities, educational opportunities for children, and community respect. Based on the estimate of the mixed logit model, willingness to pay and policy simulations were applied to estimate the utility of each attribute. Data were collected from 446 PHWs. The PHWs were willing to forgo Chinese Renminbi 2806.1 (US$ 438.5) per month to obtain better education opportunities for their children, making it the most important non-monetary factor. Their preferences were also influenced relatively more by salary, bianzhi, and community respect, than with the other attributes we tested for, work years required for promotion, career development and training opportunities, and type of health institution. Salary is a robust predictive factor, while three non-monetary factors (opportunities for children's education, bianzhi, and community respect) are essential in retaining health workers in primary care.

Evidence-based Recommendations to Improve Retention, Attraction and Recruitment of Health Workers in Sudan

Background: Current literature systematically reports that interventions to retain and attract health workers in underprivileged areas need to be context specific but rarely defines what that means. In this systematic review, the study summarized and evaluates context factors influencing the enforcement of interventions to attract and retain health workers in rural area.
 Methods: We searched online databases, pertinent websites and reference lists of selected papers to identify studies on mandatory rural service programs and financial rewarding. Four studies were selected. Information regarding context factors at macro, meso and micro levels was extracted and re-synthesized.
 Conclusion: In all the articles reviewed, policies were in placement to hold health workers, the policies appear to be ineffective because workers are still animated from rural to urban areas and from Sudan abroad. There is an utmost need than constantly before for national-level overall policy formularization on non-financial and financial remuneration if there is to be refinement in the unjust distribution of health workers across the region.

The Continuing Challenge of Maldistribution of Human Resources for Health

The Continuing Challenge of Maldistribution of Human Resources for Health

Making the case for place based governance in rural health workforce recruitment and retention: Lessons from Canada and Australia

Rural communities around the world struggle to recruit and retain health workers to service the health needs of their diverse populations. The ensuing lack of access to essential health care contributes to inequalities between rurally-located and urban-located residents. It also jeopardises the future sustainability of rural living, including in comparably high-income countries. To explore elements of place-based governance in addressing the challenges of rural health workforce recruitment and retention we utilized two case studies. We conclude by suggesting the need for an evidence base that establishes relevant, context specific benchmarks while working across national and international boundaries to enable stronger understanding of place-making strategies in rural health workforce recruitment and retention.

A Systematic Review of the Strategies to Address Health Worker Shortage in Rural and Remote Areas of Low- and Middle-Income Countries

Purpose: The aim of this paper is to examine the literature on strategies to address the maldistribution of health workers between urban and rural and remote areas of low- and middle-income countries. Sample: 16 peer-review articles that address strategies to recruit and retain health workers in rural and remote areas of low- and middle-income countries. Methods: A systematic literature review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Findings: Embase, PubMed and Web of Science, were searched resulting in 731 articles, 16 articles were included after screening. Across the 16 articles, the main categories to address the maldistribution of health workers between urban and rural and remote areas were Use of Public Sector Employment, Rural and remote Employment Incentives, Student and School Based Strategies, and Health Infrastructure and Retention. Conclusion: There is not just one type of strategy that can successfully address the maldistribution of health workers between urban and rural and remote areas. To address population health in countries suffering from maldistribution of health workers use of increasing the availability of public sector employment, increasing incentives for health workers to work in rural/ remote areas, partnering with health worker training programs and schools, and building up high quality infrastructure and other interventions to retain health workers in rural and remote areas are successful. Future research should evaluate interventions to recruit and retain health workers in rural and remote areas and look at population health as a result. The ultimate goal for recruitment and retention of health workers in rural and remote areas is improving population health and this has not been considered in past research. DOI: https://doi.org/10.14574/ojrnhc.v21i2.666

Job Satisfaction Among Public Sector Doctors and Nurses in India

In most countries, the efforts to attract and retain health workers have been focused on extrinsic measures of motivation, with very less focus on a better understanding of job satisfaction—an important intrinsic factor and construct. The main aim of this study was to assess job satisfaction, its seven dimensions, and motivation among health service providers (doctors and nurses) employed within the public sector in India. The study was conducted in three districts representing two states in India. The study participants represent the doctors and nurses from public health and service delivery centres. Data were collected from a total of 307 healthcare providers (152 doctors and 157 nurses).‘Measure job satisfaction’ tool was adapted that contained 41 items capturing seven dimensions of job satisfaction on a five-point Likert scale with a higher score indicating a higher level of job satisfaction and vice versa. In addition, one single statement was used to assess motivation.Average scores were calculated for each of the seven dimensions of job satisfaction, motivation and for overall job satisfaction. Parametric tests such as t-test and analysis of variance (ANOVA) were used for comparisons of job satisfaction scores according to the place of work, years of work experience, appointment type and health professional categories. The statistical analysis was carried out using SPSS version 22.0. Exploratory factor analysis was carried out to assess the relationship between job satisfaction and motivation and regression analysis of motivation was carried to assess predictors of job satisfaction, demographic and work-related factors’ effect on motivation.The average scores for most of the dimensions of job satisfaction were low for both doctors and nurses with the lowest scores reported for the dimensions of ‘professional support’ and ‘personal satisfaction’ while the highest score reported for ‘satisfaction with pay’. Significant results in the difference of mean scores were found for all seven dimensions of job satisfaction except for ‘prospects’ at different levels of place of work, ‘standard of care’ at different levels of length of service and ‘training’ for different levels of types of appointment. The mean scores of motivation were found to be significantly different for different levels of place of work and also between the doctors and nurses. The regression analysis of motivation on various predictors of job satisfaction suggests that personal satisfaction and satisfaction in prospect were highly significant while other variables such as gender and place of posting were marginally significant. Understanding of job satisfaction can provide useful insights to both extrinsic as well as intrinsic aspects of work motivation, which arguably is the most critical area of health systems research that could potentially feed into streamlined and improved health workforce management policies aimed at addressing the shortage and retention of the health workforce.

The health workforce: central to an effective response to the COVID-19 pandemic in Europe

BackgroundCOVID-19 has reinforced the centrality of health workers at the core of a well performing and resilient health system. It has concomitantly exposed the risks of staffing and skills shortages and the importance of protecting the health workforce. This paper focuses on highlighting some of the lessons learnt, challenges and future needs of the health workforce in Europe in the context of COVID-19.MethodsWe use secondary sources and expert information.ResultsDuring the pandemic innovative and flexible approaches were implemented to meet increasing demand for health workers and new skills and responsibilities were adopted over a short period of time. We have seen the rapid adaptation and use of new technologies to deliver care. The pandemic has underlined the importance of valuing, protecting and caring for our health workforce and the need to invest appropriately and adequately in the health workforce to have sufficient, capable and well-motivated health workers. Some of the main challenges that lie ahead of us include the imperative for better investment, to need to improve recruitment and retraining whilst better retaining health workers, a focus on domestic sustainability, redeploying and developing new skills and competences among health workers, enabling more effective multi-professional collaboration and team work, improving the quality of education and training, increasing the public health focus and promoting ethical and sustainable international recruitment of health workers.ConclusionsThe WHO European Region through its European Programme of Work 2020-2025 is fully committed to support countries in their efforts to continue to respond to COVID-19 and whilst addressing upcoming health workforce challenges.

Accommodate or Reject: The Role of Local Communities in the Retention of Health Workers in Rural Tanzania.

Background: While over 70% of the population in Tanzania reside in rural areas, only 25% of physicians and 55% of nurses serve these areas. Tanzania operates a decentralised health system which aims to bring health services closer to its people through collaborative citizen efforts. While community engagement was intended as a mechanism to support the retention of the health workforce in rural areas, the reality on the ground does not always match this ideal. This study explored the role local communities in the retention of health workers in rural Tanzania. Methods: An exploratory qualitative study was completed in two rural districts from the Kilimanjaro and Lindi regions in Tanzania between August 2015 and September 2016. Nineteen key informant interviews (KIIs) were conducted with district health managers, local government leaders, and health facility in-charges. In addition, three focus group discussions (FGDs) were conducted with 19 members of the governing committees of three health facilities from the two districts. Data were analysed using the thematic analysis technique. Results: Accommodation or rejection were the two major ways in which local communities influenced the quest for retaining health workers. Communities accommodated incoming health workers by providing them a good reception, assuming responsibility for resolving challenges facing health facilities and health workers, linking health workers to local communities and promoting practices that placed a high value on health workers. On the flip side, communities could also reject health workers by openly expressing lack of trust and labelling them as ‘foreigners,’ by practicing cultural rituals that health workers feared and discrimination based on cultural differences. Conclusion: Fostering good relationships between local communities and health workers may be as important as incentives and other health system strategies for the retention of health workers in rural areas. The role communities play in rural health worker retention is not sufficiently recognized and is worthy of further research.

Analysis of policy interventions to attract and retain nurse midwives in rural areas of Malawi: A discrete choice experiment.

Inadequate and unequal distribution of health workers are significant barriers to provision of health services in Malawi, and challenges retaining health workers in rural areas have limited scale-up initiatives. This study therefore aims to estimate cost-effectiveness of monetary and non-monetary strategies in attracting and retaining nurse midwife technicians (NMTs) to rural areas of Malawi. The study uses a discrete choice experiment (DCE) methodology to investigate importance of job characteristics, probability of uptake, and intervention costs. Interviews and focus groups were conducted with NMTs and students to identify recruitment and retention motivating factors. Through policymaker consultations, qualitative findings were used to identify job attributes for the DCE questionnaire, administered to 472 respondents. A conditional logit regression model was developed to produce probability of choosing a job with different attributes and an uptake rate was calculated to estimate the percentage of health workers that would prefer jobs with specific intervention packages. Attributes were costed per health worker year. Qualitative results highlighted housing, facility quality, management, and workload as important factors in job selection. Respondents were 2.04 times as likely to choose a rural job if superior housing was provided compared to no housing (CI 1.71-2.44, p<0.01), and 1.70 times as likely to choose a rural job with advanced facility quality (CI 1.47-1.96, p<0.01). At base level 43.9% of respondents would choose a rural job. This increased to 61.5% if superior housing was provided, and 72.5% if all facility-level improvements were provided, compared to an urban job without these improvements. Facility-level interventions had the lowest cost per health worker year. Our results indicate housing and facility-level improvements have the greatest impact on rural job choice, while also creating longer-term improvements to health workers' living and working environments. These results provide practical evidence for policymakers to support development of workforce recruitment and retention strategies.

The health workforce: Central to an effective response to the COVID-19 pandemic in the European Region.

COVID‐19 has reinforced the centrality of health workers at the core of a well performing and resilient health system. It has concomitantly exposed the risks of staffing and skills shortages and the importance of protecting the health workforce. The present commentary focuses on highlighting some of the lessons learnt, challenges and future needs of the health workforce in Europe in the context of COVID‐19. During the pandemic innovative and flexible approaches were implemented to meet increasing demand for health workers and new skills and responsibilities were adopted over a short period of time. We have seen the rapid adaptation and use of new technologies to deliver care. The pandemic has underlined the importance of valuing, protecting and caring for our health workforce and the need to invest appropriately and adequately in the health workforce to have sufficient, capable and well‐motivated health workers. Some of the main challenges that lie ahead of us include the imperative for better investment, to need to improve recruitment and retraining whilst better retaining health workers, a focus on domestic sustainability, redeploying and developing new skills and competences among health workers, enabling more effective multi‐professional collaboration and team work, improving the quality of education and training, increasing the public health focus and promoting ethical and sustainable international recruitment of health workers. The WHO European Region through its European Programme of Work 2020–2025 is fully committed to support countries in their efforts to continue to respond to COVID‐19 and whilst addressing upcoming health workforce challenges.

Retention strategies and interventions for health workers in rural and remote areas: a systematic review protocol.

The objective of the current review is to examine the association between exposure to strategies or interventions to retain health workers in rural and remote areas of high-income countries and improved retention rates. Attracting and retaining sufficient healthcare staff to provide adequate services for residents of rural and remote areas is an international problem. High-income countries have specific challenges in staffing remote and rural areas; despite the majority of the population clustering in large cities, a significant number of communities are in rural, remote or frontier areas which may be perceived as less attractive locations in which to live and work. The review will consider studies that include health workers in high-income countries where participants have been exposed to interventions, support measures or incentive programs to increase retention or workforce length of employment or reduce turnover for health workers in rural and remote areas. Analytical observational studies, case-control studies, analytical cross-sectional studies, descriptive observational study designs, and descriptive cross-sectional studies published from 2010 will be eligible for inclusion. We will use the JBI methodology for reviews of risk and etiology. A range of databases will be searched. Two reviewers will screen, critically appraise eligible articles, and extract data from included studies. Data synthesis will be conducted, where feasible, with RevMan 5.3.5. A random effects model will be used to conduct meta-analyses. We will assess the certainty of the findings using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

Employment preferences of obstetricians and gynecologists to work in the district hospitals: evidence from a discrete choice experiment in Nepal

BackgroundA mismatch between the requirement and annual production of obstetricians and gynecologists (OBs-GYNs) was observed in Nepal. On top of that, recruitment and retention of OBs-GYNs is a pressing problem, especially in district hospitals of Nepal. In this connection, evidence on the job priorities and preferences of OBs-GYNs, which is currently lacking in Nepal, would help in policymakers in devising recruitment and retention strategies in these hospitals. This study, therefore, aims at exploring the most relevant job attributes that OBs-GYNs would prefer to work in the district hospitals of Nepal using a discrete choice experiment (DCE) technique.MethodsJob attributes relevant to design the questionnaire were identified using keyinformant interviews and focusgroup discussions with policymakers and top managers. Then, 48 choice sets were developed using a fractional factorial design. Using these unlabeled choice sets, a DCE was conducted among 189 OBs-GYNs. The multinomial logistic regression model was used to estimate the marginal utilities and other model parameters. The willingness to pay/accept estimates was also measured for each job attribute.ResultsOBs-GYNs preferred the presence of a full team at the workplace (OB-GYN, pediatrician, and anesthesiologist), provision of primary and secondary education for children, and opportunity of private practice. On the other hand, a few job attributes such as a higher duration of service in district hospitalsand the provisions of a car allowance were preferred less by the respondents. Results from the marginal utility by the OBs-GYNs would be open to trade among the attributes.ConclusionsThe job attributes identified as incentives in this study should be included in a package to attract OBs-GYNs to serve in district hospitals of Nepal rather than offering a standard incentive package to all health workers. Similarly, this study confirmed the importance of the combination of non-monetary and monetary interventions in attracting and retaining health workers in district hospitals of Nepal.

Health worker transfer processes within the public health sector in Ghana: a study of three districts in the Eastern Region

IntroductionThe lack of appropriate policies and procedures to ensure transparent transfer practices is an important source of dissatisfaction among health workers in low- and middle-income countries. In order to alter and improve current practices, a more in-depth and context-specific understanding is needed. This study aims to (1) identify rationales behind transfer decisions in Ghana and (2) examine how transfers are managed in practice versus in policies.MethodsThe study took place in 2014 in three districts in Eastern Ghana. The study population included (1) national, regional, and district health administrators with decision-making authority in terms of transfer decisions and (2) health workers who had transferred between 2011 and 2014. Data was collected through semi-structured and structured face-to-face interviews focusing on rationales behind transfer decisions, health administrators’ role in managing transfers, and health workers’ experience of transfers. A data triangulation approach was applied to compare identified practices with national policies and procedures.ResultsA total of 44 health workers and 21 administrators participated in the study. Transfers initiated by health workers were mostly based on family conditions and preferences to move away from rural areas, while transfers initiated by administrators were based on service requirements, productivity, and performance. The management of transfers was not guided by clear and explicit procedures and thus often depended on the discretion of decision-makers. Moreover, health workers frequently reported not being involved in transfer decision-making processes. We found existing staff perceptions of a non-transparent system.ConclusionOur findings suggest a need to foster incentives to attract and retain health workers in rural areas. Moreover, health worker-centered procedures and systems that effectively guide and monitor transfer practices must be developed to ensure that transfers are carried out in a timely, fair, and transparent way.

Flexibility of deployment: challenges and policy options for retaining health workers during crisis in Zimbabwe

BackgroundZimbabwe experienced a socio-economic crisis from 1997 to 2008 which heavily impacted all sectors. In this context, human resource managers were confronted with the challenge of health worker shortage in rural areas and, at the same time, had to operate under a highly centralised, government-centred system which defined health worker deployment policies. This study examines the implementation of deployment policies in Zimbabwe before, during and after the crisis in order to analyse how the official policy environment evolved over time, present the actual practices used by managers to cope with the crisis and draw lessons. ‘Deployment’ here was considered to include all the human resource management functions for getting staff into posts and managing subsequent movements: recruitment, bonding, transfer and secondment. The study contributes to address the existing paucity of evidence on flexibility on implementation of policies in crisis/conflict settings.MethodsThis retrospective study investigates deployment policies in government and faith-based organisation health facilities in Zimbabwe before, during and after the crisis. A document review was done to understand the policy environment. In-depth interviews with key informant including policy makers, managers and health workers in selected facilities in three mainly rural districts in the Midlands province were conducted. Data generated was analysed using a framework approach.ResultsBefore the crisis, health workers were allowed to look for jobs on their own, while during the crisis, they were given three choices and after the crisis the preference choice was withdrawn. The government froze recruitment in all sectors during the crisis which severely affected health workers’ deployment. In practice, the implementation of the deployment policies was relatively flexible. In some cases, health workers were transferred to retain them, the recruitment freeze was temporarily lifted to fill priority vacancies, the length of the bonding period was reduced including relaxation of withholding certificates, and managers used secondment to relocate workers to priority areas.ConclusionFlexibility in the implementation of deployment policies during crises may increase the resilience of the system and contribute to the retention of health workers. This, in turn, may assist in ensuring coverage of health services in hard-to-reach areas.

Assessment of interventions to attract and retain health workers in rural Zambia: a discrete choice experiment

BackgroundWorkforce shortages, particularly in rural areas, limit the delivery of health services in Zambia. Policymakers and researchers co-created this study to identify potential non-monetary employment incentives and assess their cost-effectiveness to attract and retain public sector health workers to the rural areas of Zambia.MethodsThe study consisted of two key phases: a discrete choice experiment (DCE), preceded by a qualitative component to inform DCE questionnaire development. Firstly, in qualitative interviews with 25 health workers and focus group discussions (FGDs) with 253 health students, participants were asked to discuss job attributes and potential incentives that would influence their job choices. Based on this exercise and in consultation with policymakers, job attributes were selected for inclusion in a discrete choice experiment (DCE) questionnaire. Secondly, this questionnaire, consisting of hypothetical job “choice sets,” was presented to 474 practicing health workers and students. A conditional logit regression model was applied to the data from this DCE questionnaire to estimate preferences for various job attributes. Using administrative data, we estimated the cost of implementing potential attraction and retention strategies per health worker year worked.ResultsAlthough health workers preferred urban jobs to rural jobs (OR 1.39, 95% CI 1.11–1.75), employment incentives influenced health workers’ decision to choose rural jobs. If superior housing was offered in a rural area compared to a basic housing allowance in an urban job, participants would be five times as likely to choose the rural job (OR 5.04, 95% CI 4.12–6.18). Education incentives and facility-based improvements also increased the likelihood of rural job uptake. Housing benefits were estimated to have the lowest total costs per health worker year worked, and offer high value in terms of cost per percentage point increase in rural job uptake.ConclusionsNon-monetary incentives such as housing, education, and facility improvements can be important motivators of health worker choice of location and could mitigate rural health workforce shortages. These results can provide valuable insight into the types of job attributes and incentives that are most likely to be effective in attracting and retaining health workers in rural areas.

Analysis of strategies to attract and retain rural health workers in Cambodia, China, and Vietnam and context influencing their outcomes

BackgroundMany Asia-Pacific countries are experiencing rapid changes in socio-economic and health system development. This study aims to describe the strategies supporting rural health worker attraction and retention in Cambodia, China, and Vietnam and explore the context influencing their outcomes.MethodsThis paper is a policy analysis based on key informant interviews with stakeholders about a rural province of Cambodia, China, and Vietnam, coupled with a broad review of the literature.ResultsCambodia, China, and Vietnam have implemented medical education, provided financial incentives, and provided personal and professional support to attract and retain rural health workers. More socio-economic development was related to a wider range of interventions and their scope. The health system context influenced the outcomes. Increased autonomy of public hospitals attracted more health workers from rural primary health facilities in China and Vietnam. Health financing policies for universal health coverage in China and Vietnam have increased the utilization of health services. Subsidies for poor people to access health services in Cambodia have provided financial incentives to retain rural health workers. However, the dismantling of the referral system in China and Vietnam has resulted in a high rate of health workers moving from primary health facilities to higher-level hospitals while clear definition of primary healthcare package in Cambodia guided its planning of primary health workforce. The prosperous private health sector in Cambodia and Vietnam attracted more health workers from rural primary health facilities, impeded implementation and determined effectiveness of financial incentives.ConclusionsSocio-economic and health system reforms including health financing, public hospital autonomy, abolition of referral system and prosperous private sector have both positive and negative impacts on the design, implementation, and effectiveness of interventions to attract and retain rural health workers. Interventions to attract and retain health workers in rural and remote areas need to be considered within overall health system reform.

Contracting non-state providers for universal health coverage: learnings from Africa, Asia, and Eastern Europe

BackgroundFormal engagement with non-state providers (NSP) is an important strategy in many low-and-middle-income countries for extending coverage of publicly financed health services. The series of country studies reviewed in this paper - from Afghanistan, Bangladesh, Bosnia & Herzegovina, Ghana, South Africa, Tanzania and Uganda – provide a unique opportunity to understand the dynamics of NSP engagement in different contexts.MethodsA standard template was developed and used to summarize the main findings from the country studies. The summaries were then organized according to emergent themes and a narrative built around these themes.ResultsGovernments contracted NSPs for a variety of reasons – limited public sector capacity, inability of public sector services to reach certain populations or geographic areas, and the widespread presence of NSPs in the health sector. Underlying these reasons was a recognition that purchasing services from NSPs was necessary to increase coverage of health services. Yet, institutional NSPs faced many service delivery challenges. Like the public sector, institutional NSPs faced challenges in recruiting and retaining health workers, and ensuring service quality. Properly managing relationships between all actors involved was critical to contracting success and the role of NSPs as strategic partners in achieving national health goals. Further, the relationship between the central and lower administrative levels in contract management, as well as government stewardship capacity for monitoring contractual performance were vital for NSP performance.ConclusionFor countries with a sizeable NSP sector, making full use of the available human and other resources by contracting NSPs and appropriately managing them, offers an important way for expanding coverage of publicly financed health services and moving towards universal health coverage.

Why do people become health workers? Analysis from life histories in 4 post-conflict and post-crisis countries.

SummaryWhile there is a growing body of literature on how to attract and retain health workers once they are trained, there is much less published on what motivates people to train as health professions in the first place in low‐ and middle‐income countries and what difference this makes to later retention. In this article, we examine patterns in expressed motivation to join the profession across different cadres, based on 103 life history interviews conducted in northern Uganda, Sierra Leone, Cambodia, and Zimbabwe. A rich mix of reported motivations for joining the profession was revealed, including strong influence of “personal calling,” exhortations of family and friends, early experiences, and chance factors. Desire for social status and high respect for health professionals were also significant. Economic factors are also important—not just perceptions of future salaries and job security but also more immediate ones, such as low cost or free training. These allowed low‐income participants to access the health professions, to which they had shown considerably loyalty. The lessons learned from these cohorts, which had remained in service through periods of conflict and crisis, can influence recruitment and training policies in similar contexts to ensure a resilient health workforce.