Rural Posts Research Articles

Creation of an Emergency Care Capacity Assessment Tool for Facilities in Austere Environments.

Facilities in austere environments may consider emergency care beyond their scope. Often patients with high-acuity conditions have no other choice than to present to these facilities. The disconnect between the intent of health systems planners and the reality faced by providers manifests as facilities unable to manage such cases.The Indian Health Service, with a range of stakeholders, developed an emergency care delivery assessment tool for facilities in austere environments, designed to identify deficiencies in facility readiness for emergency care delivery across four areas: 1. Procedural2. Human resources3. Non-pharmacologic material resources4. Pharmacologic material resources. The tool's underlying architecture is a resource matrix similar to hospital-based tools, using the "Facility" component of the WHO Emergency Care Systems Framework as the Y-axis and undifferentiated presentations taught by the WHO basic emergency care course, advanced trauma life support, and advanced life support in obstetrics as the X-axis. The tool was piloted at a remote frontier clinic. We found 48 deficiencies: 7 procedural, 1 human resources, 31 non-pharmacologic materials, and 9 pharmacologic materials. We aggregated deficiencies by facility function to assess the capacity to perform each. We also aggregated deficiencies by clinical presentation to identify targets for educational interventions. We successfully created a novel emergency care capacity assessment tool for use in austere environments using materials with broad international consensus. The successful pilot found deficiencies across all 4 areas. This tool may be useful in many other remote domestic facilities and rural health posts in low- and middle-income countries.

Police relationships and engagement with rural citizens: perspectives of front-line police in the United Kingdom, Australia, and France

PurposeThis article examines challenges and strategies related to police relationships and engagement with rural communities in England and Wales, Australia and France. It aims to bridge a gap in knowledge around how police balance public demands with organisational and contextual constraints, exploring the role of communication technology in overcoming geographical and cultural barriers in rural policing.Design/methodology/approachThe research draws upon 121 semi-structured interviews conducted across three distinct jurisdictions. In the United Kingdom and Australia, interviews were conducted via Microsoft Teams, while face-to-face interviews were conducted in France. Participants were recruited through the purposive sampling of police working in rural areas. The data were thematically analysed using NVivo Software.FindingsRural communities have low expectations of policing services, a consequence of geography, organisational structures and limited resource allocation. Building relationships can be challenging owing to isolation and terrain, the need for officers to have local and cultural knowledge, and difficulties in recruiting officers in rural posts. Technology-mediated communication has played a part in the solutions (e.g. social media). However, this may not always be suitable owing to limited connectivity, citizen and police preferences for communication and engagement, and the institutional and cultural nuances surrounding the application of technology.Originality/valueThis article provides empirical insights into the attitudes and experiences of rural police officers, highlighting the distinctive policing context and engagement needs of rural communities. The research underscores the necessity for contextually aware engagement. It suggests that while technology-mediated communication offers some solutions to spatial challenges, its effectiveness may be limited by access, generational preferences and the adaptability of police institutions and cultures.

Sociological Probing of Swathed Cultural Health Systems in Yonibana, Tonkolili District, Northern Sierra Leone

In this sociological inquiry, the researcher explored the pursuit for health and healing in Yonibana, Tonkolili District, Northern Sierra Leone, unearthing the swathed forms of medical awareness and practices. This sociological inquiry organizes to pose novel and further questions about the sociology of health and healing. Incipiently, via published work, then via dominant material and social dialogues. The inquiry negotiates the successive intents: a. To portray the intricate health structure of care in Sierra Leone. b. To portray and scrutinize the social pattern of healthcare seeking behavior in an intricate, inequality and manifold healthcare structure. c. To examine social relations of cultural authority, shame and inequity in a manifold healthcare structure. d. To scan expansive social reflections of how both women and men in Northern Sierra Leone appreciate, steer and utilize divergent shapes of healthcare structures. This inquiry depicts that women and men in this district of Sierra Leone trek an intricate tour in search of their well-being challenged by the cultural inequalities and intricacies of district health care structures. The inquiry summarises by depicting that the folks of this district, manifest agency in their health practices, and their health seeking behaviour and actions are adjusted in an effort to facilitate their wellness. Given the gendered and patriarchal context of Sierra Leonean culture, the findings of this study are perhaps surprising that birthing women reported male midwives to be more gentle, calm, and respectful than female midwives, and that nurses who work in rural health posts are perceived to be more respectful than the nurses who work at central hospitals, thus these findings may suggest more need to explore these two themes.

MicroDoc: Developing a guide for managing infections in Zambian rural low-resource health settings

Abstract Lack of access to diagnostic tests and guidelines that are inappropriate for poorly resourced facilities can result in incorrect and excessive prescribing of antimicrobial therapy in rural healthcare settings. On Call Africa (OCA) and Virtual Doctors (VD) are two non-governmental organisations that work in healthcare in Zambia. Volunteers and staff from OCA and VD have collaborated with the Zambian Ministry of Health and local healthcare providers to design a guide to support decisions around management of infections specifically in rural primary healthcare settings in Zambia. Local staff were initially surveyed for their attitudes towards treatment of infections, the content they would like capacity building in, and preferred modes of learning. The team, comprising public health and infectious disease doctors and GPs from Ireland and the UK with experience working in Zambia, have created a guide called MicroDoc which encompasses workshops, PDFs, flowcharts and modules relating to management of infections and antimicrobial prescribing. All the content can be downloaded and accessed offline. The Zambian Standard Treatment Guidelines were consulted for antimicrobial choice, supplemented by NICE and WHO where necessary. Red flags for urgent hospital referral are also incorporated, as well as modules about risks of antimicrobial resistance. Early versions of the guide have been distributed to a range of facilities in Zambia's Southern Province, with promising feedback from healthcare providers. In collaboration with local partners and input from facility staff, MicroDoc will be finalised and rolled out to more health posts and health centres in the region, with a view to eventually expanding to other regions. The OCA team has been conducting clinical audits of prescribing practices in two rural health posts and it is hoped that the MicroDoc guide will contribute to improved antimicrobial stewardship as well as better outcomes for patients. Key messages • Management of infectious presentations is particularly challenging in rural low-resource primary healthcare settings in Sub-Saharan countries such as Zambia. • A team from On Call Africa and Virtual Doctors has created a guide called MicroDoc, in collaboration with Zambian health authorities, to support decision making in managing infections in primary care.

ДИНАМИКА ОБЕСПЕЧЕННОСТИ СРЕДНИМ МЕДИЦИНСКИМ ПЕРСОНАЛОМ ГОСУДАРСТВЕННЫХ МЕДИЦИНСКИХ ОРГАНИЗАЦИЙ РОССИЙСКОЙ ФЕДЕРАЦИИ В ПЕРИОД С 2018 ПО 2022 ГОД

Significance. Nursing staff play an important role in health care delivery. Specialists with secondary medical education provide "independent" medical care at rural health posts and stations (departments) of emergency medical care. Consequently, the density of such staff affects both the care availability and quality, substantiating the relevance of the study of staffing of health facilities with nurses. The purpose of the study. To analyze dynamics in the number of nurses in health facilities of the Russian Federation in 2018-2022. Material and methods. Statistical materials "Resources and activities of medical organizations" on the number of nursing staff in health facilities in the Russian Federation, federal districts and constituent entities of the Russian Federation for the period from 2018 to 2022 were used. When calculating indicators, methodological recommendations of the Ministry of Health of the Russian Federation were used. Analytical and statistical methods were used in the research process. Calculations were performed using Excel 2019 spreadsheets. Results. The results of the analysis of the number of nurses for the last five years show a 6.5% decline. In the Russian Federation, there are significant territorial differences in the number of nursing staff per population (per 10,000 population), which can be traced throughout the entire period under study. It has been revealed that the average age of nurses in the country as a whole equals to 42.62 years. Conclusion. A study on key indicators characterizing the staffing level has shown that the number of nursing staff in the country as a whole in 2022 decreased by 6.5% compared to 2018. However, 34 constituent entities of the Russian Federation report the value of 90.0 or higher per 10,000 population, which is optimal. The indicator of staffing of full-time positions with individuals decreased to 71.5%, with a secondary employment ratio of 1.3. Analysis of dynamics of the average age of nursing staff over a five-year period showed a 0.93 year increase. Scope of application. The study results can be of interest to health officials, practitioners, residents and graduate students of medical universities.

The Iranian blood pressure measurement campaign, 2019: study protocol and preliminary results.

Hypertension is one of the most important risk factors for premature mortality and morbidity in Iran. The objective of the Iranian blood pressure (BP) measurement campaign was to identify individuals with raised blood pressure and providing appropriate care and increase the awareness among the public and policymakers of the importance of tackling hypertension. The campaign was conducted in two phases. The first (communication) phase started on May 17th (International Hypertension Day). The second phase started on June 8th, 2019, and lasted up to July 7th during which, blood pressures were measured. The target population was Iranians aged ≥ 30 years. Participants voluntarily referred to health houses in rural and health posts and comprehensive health centers in urban areas in the setting of the Primary Health Care network. Additionally, over 13,700 temporary stations were set up in highly visited places in urban areas. Volunteer healthcare staff interviewed the participants, measured their BP, and provided them with lifestyle advice and knowledge of the risks and consequences of high blood pressure. They referred participants to physicians in case their BP was high. Participants immediately received a text message containing the relevant advice based on their measured BP and their past history. Blood pressure was measured for a total of 26,678,394 participants in the campaign. A total of 13,722,148 participants (51.4%) were female. The mean age was 46 ± 14.1 years. Among total participants, 15,012,693 adults (56.3%) with no past history of hypertension had normal BP, 7,959,288 participants had BP in the prehypertension range (29.8%), and finally, 3,706,413 participants (13.9%) had either past medical history of hypertension, used medications, or had high BP measured in the campaign. The campaign was feasible with the objective to increase the awareness among the public and policymakers of the importance of tackling hypertension in Iran.

Factors influencing attraction and retention of frontline health workers in remote and rural areas in Nigeria: a discrete choice experiment.

The policy thrust in Nigeria is to ensure qualified, skilled, and adequate health workforce to achieve universal health coverage. We designed a discrete choice experiment to determine the combinations of incentives that may increase the attraction and retention of frontline health workers. We conducted the study in Bauchi State amongst 145 students and health workers. Health workers are 14.6 and 14.4 times more likely to take up a rural posting or continue to stay in their present rural posts if there was basic housing and improvement of the quality of the facilities respectively. The preference for rural job location increased 6.17 times when good schools for children's education were provided. Ensuring availability of basic housing, improving the quality of health facilities, and ensuring good schools for children's educations are essential factors that may support attraction and retention of health workers. These strategies will support health care services in rural areas and achieving universal health coverage.

The quality of service provision to newborns in the primary healthcare, West Gojjam zone, North-West of Ethiopia: a cross-sectional survey

BackgroundDuring 2019, neonatal conditions in Ethiopia accounted for 55% of under-5 deaths, with 33 neonatal deaths occurring for every 1000 live births. More than 80% of all newborns deaths are caused by preventable and treatable conditions with available interventions. In Ethiopia, mortality rates for newborn babies have remained stubbornly high over the decades.ObjectiveThis research aimed to assess the quality-of-service provision for newborns in the primary healthcare units in the North-West of Ethiopia.MethodsA cross-sectional survey design was employed. Interviewer-administered questionnaires were administered to 221 health workers and health extension workers, and health facility readiness assessment was done in 142 health facilities including 3 Primary hospitals, 76 Health centres and 63 Health posts from April to July 2017. Data was entered into the EpiData 3.1, exported to SPSS and STATA for analysis. Descriptive and regression multivariate analysis was applied.ResultsOut of the 10 quality of newborn care variables, 8.7 [95%CI: 6.03–11.303], the highest mean was achieved by primary hospitals, followed by urban health centres with a 6.4 mean [95%CI:5.168–7.601]. However, nearly half of the rural health centres were providing quality of newborn care at the mean of 5.7 [95%CI: 5.152–6.18], and below half was provided by health posts, 4.5 [95%CI: 3.867–5.116]. From the seven emergency newborn care signal functions, primary hospitals had a higher mean score, 6.3 [95%CI: 6.007–7.325] and rural health centres had the lowest mean score, 2.3 [95%CI: 2.043–2.623]. The availability of essential equipment is also significantly associated with the quality of neonatal care provision in the health facilities (p < 0.05). Overall, the effectiveness of the neonatal healthcare services has a significant association with the health facility readiness score [95%CI: 0.134–0.768].ConclusionThe quality of newborn care was high at the higher-level health facilities and lower in the lower-level health facilities such as rural health centres and health posts, where these facilities are an entry point to the health system and are expected to provide the essential newborn care services to the majority of the rural communities. In addition, the provision of emergency newborn care signal functions was critically low in rural health centres where these are referral receiving health facilities from health posts. Thus, rural health centres and health posts should be targeted to improve their readiness to provide the quality of services for newborns as per their expected level of care.

ACCESS TO PUBLIC HEALTH SERVICES FOR DIFFERENT GROUPS OF RURAL POPULATION IN RUSSIA

During the COVID-19 pandemic, the problems of accessibility of primary health care and quality health services for rural residents are exacerbated. The purpose of the article is to conduct comparative studies of the access to public health services of rural medical posts (RMPs), polyclinics, specialized medical facilities for different groups of the rural population of Russia. The results of the studies showed that the majority of rural residents living in small remote settlements request medical assistance at the RMPs. Among those who requested medical assistance, 70.7% were over 45 years old, and 43.9% were pensioners. Most of them have low requirements for medical assistance. They are primarily interested in the services provided for free. Younger rural residents (35.2% under the age of 45 years) request medical assistance at polyclinics, 47.8% of them are self-employed, and about 71.1% are low-income groups. The main reasons for applying for paid medical care, they call the lack of specialists in public institutions. Visitors to specialized centers have the highest requirements for the quality of medical services received. The maximum share belongs to young people (24.4% of people aged 16-30 and 20.3% aged 31-45), about 60.5% have jobs, 40.6% have incomes higher than the subsistence level. They are more likely than others to seek paid medical services. The main reason for choosing commercial institutions is the belief that paid medical services are of better quality. The construction of multidimensional distributions was performed using the statistical processing package STATISTICA Advanced for Windows 10.0.

Retention and motivation of health workers in remote and rural areas in Cross River State, Nigeria: a discrete choice experiment.

Cross River State is making investments geared towards ensuring equitable distribution and improved retention of its frontline health workforce in remote and rural areas. This informed the conduct of a discrete choice experiment to determine the motivating factors supporting the retention of healthcare workers. Study participants were 198 final year students of nursing, midwifery and community health and frontline health workers. Eight focus group discussions and 38 key informant interviews were conducted to obtain information about the dimensions of the work conditions that are important to frontline health workers when choosing to take up posting or stay in their rural work locations. Health workers are 2.7 times more likely to take up a rural posting or continue to stay in their present rural duty posts if they receive a salary increment. They are also four times more likely to take a rural job posting if a basic housing or a housing allowance is provided. Improving working conditions of frontline health workers in terms of adequate staff strength, good skills mix and equipment, etc., as well as improving opportunities for career advancement will support retention in rural health posts.

Factors Associated With Delayed Contraceptive Implant Removal in Ethiopia.

In 2009, the Government of Ethiopia initiated the implant scale-up initiative, which expanded contraceptive access by training health extension workers (HEWs) to insert single-rod etonogestrel contraceptive implants (Implanon) at rural health posts. Removals were provided by referrals to higher levels of the health system. However, little was known about whether women were getting their implants removed at the recommended 3-year postinsertion date or what barriers they faced to removal. Between June and July 2016, 1,860 Ethiopian women, who had a 1-rod etonogestrel implant inserted by either an HEW or another health care provider between 3 and 6 years prior, were surveyed. We describe the characteristics of the sample and use multivariable logistic regression to predict factors associated with keeping implants inserted beyond 3 years. Women who had received their implants from HEWs were significantly more likely to report keeping them inserted for more than 3 years (adjusted odds ratio=2.50; 95% confidence interval=1.19, 5.24), compared with those who got their implant from another health care provider. Women who reported distance to the facility or transportation as a barrier were also significantly more likely to keep their implant for more than 3 years. Married and educated women were less likely to keep their implants for an extended duration. Among women who had their implant for 3 years or less, women who had had it inserted by an HEW were significantly more likely to report that the provider was unable or refused to provide removal as a barrier. Efforts to expand lower level and community-based access to contraceptive implants that do not ensure reliable access to removals at the same level as insertions may lead to women using implants beyond the recommended duration.

Work Preferences in Rural Health Job Posting Among Medical Interns in a Lower Middle-Income Country-a Discrete Choice Experiment.

Introduction:Timely empirical evidence is important in the success of health systems, and such evidence is necessary for informed policy making to address inequity in the health workforce. Literature is ripe with incentives that affect recruitment and retention of physicians in rural and remote areas, but such data in still lacking in the Philippine setting. Discrete choice experiment is one methodology utilized by the World Health Organization which provides both qualitative and quantitative information to aid policy makers in health human resource management.Methods:The study utilized a discrete choice experiment involving three phases: 1) identification of incentives and levels using key informant interviews and focus group discussions, 2) selection of scenarios utilizing an experimental design, and 3) administration of survey based on WHO guidelines. Conditional logistic regression, point estimates, and correlational analyses were done using Stata.Results:There is significant association between type of background and considerations for rural practice among the respondents based on Pearson's correlation (p < 0.01). The respondents put more value into non-wage rural job posting incentives than small to modest base salary increases. The high willingness to pay for the presence of supervision, relative location of work areas from families, and status of workplace infrastructure/equipment or supplies suggest the importance of workplace conditions to attract rural health physicians. Combinations of wage and non-wage incentives may be necessary to provide for the most cost-efficient increases in rural job post uptake rates based on post-estimate calculations.Conclusion:Philippine medical interns and young doctors value non-wage incentives in considering rural health job postings. Rural health job postings with these incentives are predicted to significantly increase recruitment in rural health job posts, particularly when combinations of wage and high-impact non-wage incentives are considered.

Telemedicine and epilepsy: A patient satisfaction survey of a pediatric remote care program

PurposeThe aim of this study was to assess parent satisfaction three years after the implementation of a pediatric epilepsy telemedicine program. MethodsThe program was developed with support from the Ministry of Health through Hospital Nacional de Pediatría J.P. Garrahan. A secure internet connection was used for high-speed, high-definition video and audio. Synchronous face-to-face consultation between the patient and the neurologist was used.To evaluate the success of the program, at the end of the consultation the parent or caregiver of the patient was asked to complete a survey evaluating satisfaction with health care, cost, and privacy issues. The survey was administered by community health workers to the parents of patients that were in follow-up or first seen at the rural health posts during 2019. ResultsBetween January and December 2019, 116 consecutive parents of patients seen at the epilepsy telemedicine clinic filled out a semistructured questionnaire. Mean age of the patients was 8.5 years (range, 1–17 years); 85 % of the patients had a follow-up of more than 6 months. All the families felt supported by the team and were satisfied with the program in terms of epilepsy management. Less work- and schooltime lost, less travel time and costs, better access to medication, and more regular follow-up visits were reported. The parents considered they had received clear information about the epilepsy of their child. ConclusionTelemedicine proves to be an important tool in the comprehensive management of people with epilepsy.

National Healthcare System Development of Ethiopia: A Systematic Narrative Review

Objective: To describe the evidence on the development of the National Healthcare System in Ethiopia. Method: The databases Embase, Ovid Emcare, Ovid MEDLINE, and Scopus were searched, together with the reference lists of the identified articles, relevant reports and books were searched. Articles were included if they described health services development in Ethiopia. Results: In Ethiopia, medical care has historically been performed by traditional healers who use magic and superstition. Over time, modern medicine continued to develop, and by 2014, 5% of Ethiopia’s total Gross Domestic Product was spent on health. In 2017, nearly 1.26 healthcare workers per 1000 population provided services through 21,071 healthcare organizations, with the majority being rural health posts. There are shortages of healthcare workers and limited numbers of hospitals. However, the introduction of the Health Extension Program and Health Extension Workers has improved access to healthcare in the country and could be a model for other African nations. Conclusion: Although the health care strategies introduced by the Ethiopian government have improved some health issues, accessibility to healthcare institutions that provide curative services is limited.

Assessing satisfaction and motivation of health extension workers (Hews) and factors associated with it in gambella region, Gambella, southwest Ethiopia, 2019: A cross-sectional study

Background: Health extension workers (HEWs) are the frontline health workers for Ethiopia’s primary health care system. The Health Extension Program (HEP) is one of the most innovative community- based health programs launched by the Ethiopian Federal Ministry of Health (FMOH) to make health services accessible to rural communities by setting out women health extension workers (HEWs) in rural health posts. Ethiopia has initiated a nationwide community health program (referred to as Health Extension Program) that is primarily staffed with health extension workers; however, data on their satisfaction and motivation and related factors were not studied and scanty in the country. Thus, this study was aimed to assess measure the satisfaction of health extension workers and to identify factors affecting their satisfaction in the study setting in particular and the country in general. Materials and Methods: A cross-sectional descriptive study analysis was conducted to collect relevant data on satisfaction from health extension workers who had been from three districts in Southwest Ethiopia. Items included in the questionnaires include values, organizational cultures, work place conditions, personality, motivating and satisfaction. They also included reasons for satisfaction and dissatisfaction; motivating and de-motivating from future perspectives using Likert scale. Mean and standard deviation were used to describe satisfaction level. Multiple linear regression model was used for identifying associated factors. Result: The overall mean satisfaction score was 43.0 out of the 60 total score. Organizational culture, personal recognition and appreciation, job descriptions and criteria career structure and for promotion salary have been identified by rural HEWs as major were mentioned as a reason for satisfaction and motivating; while low salaries, insufficient training and lack of capacity among others, absence of transportation, poor supervision, and absence of housing living conditions were mentioned as reasons for dissatisfaction and de-motivating. Conclusion: HEWs play a pivotal role in Ethiopia’s HEP. As such, their motivations require special consideration to support them to continue doing their health care activities in a productive way. The HEWs were least satisfied with Salary pay, education, and benefits which require high level decision for strategies to improve the pay and benefits, and opportunities for education. They were also least satisfied with management and working conditions that can be addressed at organization level by supportive supervision and management, participatory decision making, clear job descriptions, merit based recognition and appreciation and balanced workload.

MOBILE H EALTH TECHNOLOGY: ORGANIZATIONAL, MEDICAL AND PHARMACOEPIDEMIOLOGICAL APPROACHES FOR CSD PREVENTION IN PRE-PRIMARY CARE

Objective: to evaluate the innovative organizational, medical and pharmacoepidemiological approaches for the prevention of circulatory system diseases in pre-primary care using mobile health technologies.Materials and methods: 3,694 people went through preventive consultation (questionnaires, anthropometry, body fat and blood pressure evaluation, electrocardiography, glucose and blood cholesterol) at equipped medical sites in shopping centers and rural health posts.Results. Among the surveyed, there were both healthy people and patients cardiovascular diseases and diabetes mellitus. Behavioral (insufficient consumption of fruits and vegetables, adding more salt without trying food, physical inactivity, smoking and alcohol abuse) and nutritional (obesity, hypertension, hypercholesterolemia and glycaemia) risk factors of chronic noncommunicable diseases were detected that contribute to high mortality from circulatory system diseases in the Tver region. This is associated with low adherence to drug therapy and its lack of efficacy in patients with hypertension, ischemic heart disease and cerebrovascular diseases.Conclusion: to assess the effectiveness of CSD prevention in pre-primary care, it is possible to use mobile medical sites in shopping centers and rural health posts.

For more than money: willingness of health professionals to stay in remote Senegal

BackgroundPoor distribution of already inadequate numbers of health professionals seriously constrains equitable access to health services in low- and middle-income countries. The Senegalese Government is currently developing policy to encourage health professionals to remain in areas defined as ‘difficult’. Understanding health professional’s preferences is crucial for this policy development.MethodsWorking with the Senegalese Government, a choice experiment (CE) was developed to elicit the job preferences of physicians and non-physicians. Attributes were defined using a novel mixed-methods approach, combining interviews and best-worst scaling (Case 1). Six attributes were categorised as ‘individual (extrinsic) incentive’ attributes (‘type of contract’, ‘provision of training opportunities’, ‘provision of an allowance’ and ‘provision of accommodation’) or ‘functioning health system’ attributes (‘availability of basic equipment in health facilities’ and ‘provision of supportive supervision by health administrators’). Using face-to-face interviews, the CE was administered to 55 physicians (3909 observations) and 246 non-physicians (17 961 observations) randomly selected from those working in eight ‘difficult’ regions in Senegal. Conditional logit was used to analyse responses. This is the first CE to both explore the impact of contract type on rural retention and to estimate value of attributes in terms of willingness to stay (WTS) in current rural post.ResultsFor both physicians and non-physicians, a permanent contract is the most important determinant of rural job retention, followed by availability of equipment and provision of training opportunities. Retention probabilities suggest that policy reform affecting only a single attribute is unlikely to encourage health professionals to remain in ‘difficult’ regions. The relative importance of an allowance is low; however, the level of such financial incentives requires further investigation.ConclusionContract type is a key factor impacting on retention. This has led the Senegalese Health Ministry to introduce a new rural assignment policy that recruits permanent staff from the pool of annually contracted healthcare professionals on the condition that they take up rural posts. While this is a useful policy development, further efforts to retain rural health workers, considering both personal incentives and the functioning of health systems, are necessary to ensure health worker numbers are adequate to meet the needs of rural communities.

Perceptions of palliative care in a lower middle-income Muslim country: A qualitative study of health care professionals, bereaved families and communities

Background: Palliative care has been successfully integrated into many Muslim-majority countries, most frequently in urbanised areas with developed health care systems. Less is known as to how the concept of palliative care is perceived by Muslim populations and health workers in rural, resource-limited contexts. Aim: This study seeks to explore whether the principles of palliative care are congruent with the perspectives of health professionals, families and communities in rural areas of the Islamic Republic of Mauritania, in West Africa. Design: A qualitative research design was employed underpinned by a constructionist paradigm. Data were collected through 31 interviews and 8 focus groups. Data were analysed using thematic analysis. Setting/participants: A total of 76 participants were recruited from across rural Mauritania; 33 health care professionals, 12 recently bereaved family members and 31 community leaders. Data collection occurred during training events in the capital and visits to villages and rural health posts. Results: Three major themes were identified. First, there is a perceived lack of congruency between an illness which limits life and the strong belief in destiny. The second theme describes the perceived barriers to communication of issues relating to palliative care. Finally, a good death is described, framed within the interplay of religious faith and cultural practices. Conclusion: The palliative care ethos is viewed positively by the majority of participants. The need to understand and respect a Muslim individual’s faith does not diminish our obligation to personalise palliative care provided for them and their family.

Role of the general practitioner in improving rural healthcare access: a case from Nepal

BackgroundThere is a global health workforce shortage, which is considered critical in Nepal, a low-income country with a predominantly rural population. General practitioners (GPs) may play a key role improving access to essential health services in rural Nepal, though they are currently underrepresented at the district hospital level. The objective of this paper is to describe how GPs are adding value in rural Nepal by exploring clinical, leadership, and educational roles currently performed in a rural district-level hospital.Case presentationWe perform a descriptive case study of clinical and non-clinical services offered at Bayalpata Hospital prior to and following the initiation of GP-level services in 2013. Bayalpata is a district-level public hospital managed through a public private partnership by the nonprofit healthcare organization Possible. We found that after general practitioners were hired, additional clinical services included continuous emergency obstetric care, major orthopedic surgeries, appendectomy, tubal ligation, and vasectomy. This time period was associated with increased emergency department visits, inpatient admissions, and institutional birth rate in the hospital’s catchment area. Non-clinical contributions included the development of a continuing medical education curriculum and implementation of a series of quality improvement initiatives.ConclusionsGPs have potential to bring significant value to rural district hospitals in Nepal. Clinical impact may include expanded access to surgical and emergency obstetric services, which would more fully align with local health needs, and could further reduce Nepal’s maternal mortality rate. Task-shifting and structured training programs would be required to increase orthopedic surgery capacity, but this would contribute to meeting local healthcare needs. Non-clinical impact may include supervision of health workers and leadership in continuing medical education and quality improvement initiatives. These changes can lead to improved health worker recruitment and retention in rural posts. Limitations include generalizability of our results to other district hospitals in Nepal and lack of data from control hospitals. This analysis provides an additional perspective on the potential value GPs can add in rural Nepal, through provision of a wide range of clinical and non-clinical services. It supports the expansion of GPs to additional district hospitals in Nepal’s public sector.

Retaining Doctors in Rural Bangladesh: A Policy Analysis.

Background: Retaining doctors in rural areas is a challenge in Bangladesh. In this study, we analyzed three rural retention policies: career development programs, compulsory services, and schools outside major cities – in terms of context, contents, actors, and processes. Methods: Series of group discussions between policy-makers and researchers prompted the selection of policy areas, which were analyzed using the policy triangle framework. We conducted document and literature reviews (1971-2013), key informant interviews (KIIs) with relevant policy elites (n=11), and stakeholder analysis/position-mapping. Results: In policy-1, we found, applicants with relevant expertise were not leveraged in recruitment, promotions were often late and contingent on post-graduation. Career tracks were porous and unplanned: people without necessary expertise or experience were deployed to high positions by lateral migration from unrelated career tracks or ministries, as opposed to vertical promotion. Promotions were often politically motivated. In policy-2, females were not ensured to stay with their spouse in rural areas, health bureaucrats working at district and sub-district levels relaxed their monitoring for personal gain or political pressure. Impractical rural posts were allegedly created to graft money from applicants in exchange for recruitment assurance. Compulsory service was often waived for political affiliates. In policy-3, we found an absence of clear policy documents obligating establishment of medical colleges in rural areas. These were established based on political consideration (public sector) or profit motives (private sector). Conclusion: Four cross-cutting themes were identified: lack of proper systems or policies, vested interest or corruption, undue political influence, and imbalanced power and position of some stakeholders. Based on findings, we recommend, in policy-1, applicants with relevant expertise to be recruited; recruitment should be quick, customized, and transparent; career tracks (General Health Service, Medical Teaching, Health Administration) must be clearly defined, distinct, and respected. In policy-2, facilities must be ensured prior to postings, female doctors should be prioritized to stay with the spouse, field bureaucrats should receive non-practising allowance in exchange of strict monitoring, and no political interference in compulsory service is assured. In policy-3, specific policy guidelines should be developed to establish rural medical colleges. Political commitment is a key to rural retention of doctors.