Getting and keeping health workers in remote and rural
areas: the WHO global policy recommendations
Dr Carmen Dolea
Department of Human Resources for Health, WHO, Geneva
Presented by: Prof James Buchan, QMU
jbuchan@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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The 16 WHO global policy recommendations
Category of intervention
Examples
A1 Students from rural backgrounds
A2 Health professional schools outside of major cities
A. Education
A3 Clinical rotations in rural areas during studies
A4 Curricula that reflect rural health issues
A5 Continuous professional development for rural health workers
B1 Enhanced scope of practice
B. Regulatory
B2 Different types of health workers
B3 Compulsory service
B4 Subsidized education for return of service
C. Financial incentives
C1 Appropriate financial incentives
D1 Better living conditions
D2 Safe and supportive working environment
D. Professional and personal
support
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D3 Outreach support
D4 Career development programmes
D5 Professional networks
D6 Public recognition measures
Education interventions: the “rural pipeline”
Support of rural HCWs: nurturing the RIGHT ENVIRONMENT
Career ladders for rural health workers (South Africa)
Postgraduate training: creating the RIGHT OPPORTUNITIES
Rural residency programmes (Sudan, Australia, Canada)
Undergraduate training: getting the RIGHT CONTEXT
create schools outside major cities (Mali, Canada)
rural clinical placements in rural areas (Australia)
changes in curricula (South Africa)
Student selection: choosing the RIGHT PEOPLE
targeting admission of students from a rural background (Sudan; Thailand)
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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
Situation analysis
Choosing the
interventions:
what criteria?
Monitoring and
evaluation
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• Identify health service needs
• Labour market analysis
• Understanding preferences and health workers needs
• Effectiveness: does it work?
• Relevance: time to impact, enforcement capacity, regulatory
framework, urban underemployment
• Acceptability: stakeholders engagement
• Affordability: sources of funds, sustainability
• Complementarities with other interventions
•
•
•
•
Plan for it from the beginning
Indicators: outcomes of interest , impact
Methods and tools: capacity of health information systems
Roles of stakeholders and partners
Roadmap and tools for implementation
Monitoring and evaluation:
WHO framework: design, process,
Indicators, outcomes of interest
Implementation:
Human resources management systems
Performance appraisal system,
including awards
Source: Draft WHO/CapacityPlus/WB
roadmap to support implementation of rural
retention strategies
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Understanding the problem:
Scope of the problem
Factors affecting decisions of location
Preferences and choices (DCE)
Labour market survey
Choosing the interventions:
Effectiveness
Relevance: time to impact,
enforcement capacity,
urban underemployment
Acceptability: stakeholder analysis
Affordability: costing tool
Complementarities
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
intervention
SHORT-TERM
MEDIUM-TERM
(or timeframe difficult to
determine)
A5. Continuous professional
development for rural
health workers
A3. Clinical rotations in
rural areas during
studies
B1. Enhanced scope of
practice (task-shifting)
B3. Compulsory service
B4. Subsidized education for
return of service
B2. Different types of
health workers (midlevel cadres)
EDUCATION
REGULATORY
FINANCIAL
INCENTIVES
PROFESSIONAL AND
PERSONAL
SUPPORT
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LONG-TERM
A1. Student from rural
background
A2. Health professional
schools outside the
major cities
A4. Curricula that reflect
rural health issues
C1. Appropriate financial
incentives
D2. Safe and supportive
working environment
D5. Professional networks
D6. Public recognition
measures
D1. Better living
conditions
D3. Outreach support
D4. Career development
programmes
Source: Draft
WHO/CapacityPlus/WB roadmap
to support implementation of rural
retention strategies
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
Finance
Development
partners
World Bank
Education
and
regulatory
interventions
Ministry of
Labour
WHO
GAVI
Ministry of
Health
The Global Fund
PEPFAR
Ministry of
Higher
Education
Direct and
indirect
financial
incentives
Management,
environment
and social
support
Civil Service
Commission
Ministry of
Transport
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Ministry of
Public
Administration
Health
workers
Professional
Associations
Populations/
Communities
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
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