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Getting and keeping health workers in remote and rural areas: the WHO global policy recommendations

Dr Carmen DoleaDepartment of Human Resources for Health, WHO, Geneva

Presented by: Prof James Buchan, QMUjbuchan@qmu.ac.uk

http://www.who.int/hrh/retention/guidelines/en/index.html

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Overview – developing the WHO recommendations

• Why “guidelines”?

• How did we go about it?

• What are the WHO recommendations?

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Why “guidelines” for rural retention

• "Recommendation/guideline" implies a course of action needs to be taken AND that progress can be measured against a set baseline

• "Policy options" are good, but may remain "optional", not "actioned upon"

• Systematic, explicit and transparent process of evidence gathering/assessment and of formulating the recommendations

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How did we go about it

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Access to health workers in remote and rural areas depends on two inter-related aspects

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Factors influencing decisions to stay in or leave rural and remote areas

• Personal– Rural background (origin), values, altruism

• Family and community– Provision of schooling for children, sense of community spirit, community

facilities available• Financial aspects

– Benefits, allowances, salaries, payment system• Career related

– Access to continuing education opportunities, supervision, professional development courses/ workshops etc, senior posts in rural areas

• Working and living conditions– Infrastructure, working environment, access to technology/medicines,

housing conditions etc• Bonding or mandatory service:

– Whether obligated to serve there Source: WHO 2010

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Category of intervention Examples

A. Education

A1 Students from rural backgrounds

A2 Health professional schools outside of major cities

A3 Clinical rotations in rural areas during studies

A4 Curricula that reflect rural health issues

A5 Continuous professional development for rural health workers

B. Regulatory

B1 Enhanced scope of practice

B2 Different types of health workers

B3 Compulsory service

B4 Subsidized education for return of service

C. Financial incentives C1 Appropriate financial incentives

D. Professional and personal support

D1 Better living conditions

D2 Safe and supportive working environment

D3 Outreach support

D4 Career development programmes

D5 Professional networks

D6 Public recognition measures

The 16 WHO global policy recommendations

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Education interventions: the “rural pipeline”

Student selection: choosing the RIGHT PEOPLEtargeting admission of students from a rural background (Sudan; Thailand)

Undergraduate training: getting the RIGHT CONTEXTcreate schools outside major cities (Mali, Canada) rural clinical placements in rural areas (Australia) changes in curricula (South Africa)

Postgraduate training: creating the RIGHT OPPORTUNITIESRural residency programmes (Sudan, Australia, Canada)

Support of rural HCWs: nurturing the RIGHT ENVIRONMENTCareer ladders for rural health workers (South Africa)

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Regulatory interventions: different types of health workers or different types of contracts

• Compulsory service: not always effective, requires reinforcement and heavy administration

• Enhancing the scope of practice for rural health workers: more duties and responsibilities, not always accompanied with adequate rewards

• Different types of health workers: clinical officers a potential solution

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Financial incentives: how much is "large enough"?

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Professional and personal support: most likely to work, yet very little done for it– Living and working conditions– Professional networks, journals etc– Outreach support/telemedicine – Career ladders for rural health workers

– Titles, awards, public recognition

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Retention strategies – from planning to implementation, monitoring and evaluation

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Monitoring and evaluation:WHO framework: design, process,

Indicators, outcomes of interest

Implementation:Human resources management systems

Performance appraisal system, including awards

Choosing the interventions:Effectiveness

Relevance: time to impact, enforcement capacity,

urban underemploymentAcceptability: stakeholder analysis

Affordability: costing toolComplementarities

Understanding the problem:Scope of the problem

Factors affecting decisions of locationPreferences and choices (DCE)

Labour market survey

Roadmap and tools for implementation

Source: Draft WHO/CapacityPlus/WB roadmap to support implementation of rural retention strategies

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Choosing the most appropriate interventions

• Decisions often driven by everything else but evidence• However, some essential criteria need to be considered

before selecting a package:– Effectiveness– Relevance:

• Time to impact• Enforcement capacity• Urban underemployment

– Acceptability– Affordability– Complementarities

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Time to impact Category of

interventionSHORT-TERM MEDIUM-TERM

(or timeframe difficult to determine)

LONG-TERM

EDUCATION

A5. Continuous professional development for rural health workers

A3. Clinical rotations in rural areas during studies

A1. Student from rural background

A2. Health professional schools outside the major cities

A4. Curricula that reflect rural health issues

REGULATORY

B1. Enhanced scope of practice (task-shifting)

B3. Compulsory serviceB4. Subsidized education for

return of service

B2. Different types of health workers (mid-level cadres)

FINANCIAL INCENTIVES

C1. Appropriate financial incentives

PROFESSIONAL AND PERSONAL SUPPORT

D2. Safe and supportive working environment

D5. Professional networksD6. Public recognition

measures

D1. Better living conditions

D3. Outreach supportD4. Career development

programmes

Source: Draft WHO/CapacityPlus/WB roadmap to support implementation of rural retention strategies

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Monitoring and evaluation: a framework for measuring results

Number of students from rural background reporting their intention to practice in rural/remote/underserved area

Number of students from rural background selected/recruited into medical or health professional schools

Number of students from rural background retained in rural/remote/underserved area

Source, WHO, 2010

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A complex issue in a complex environment

Ministry of Health

Ministry of Finance

Ministry of Labour

Ministry of Public

Administration

Health workers

Populations/Communities

Civil Service Commission

Ministry of Transport

Professional Associations

Ministry of Higher

Education

GAVI

The Global Fund

PEPFAR

Development partners

World Bank WHO

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Thank you for your attention!

For further information, please contact Dr Carmen Dolea: doleac@who.int

http://www.who.int/hrh/retention/guidelines/en/index.html