Prepared by: Jenny Moberg
Date: 18 October 2012
Health system and public health evidence to decision framework – multiple options
Overview of options from the World Health Organization global policy recommendations to increase rural accessibility to health care workers
Problem: Poor access to skilled health workers in
rural areas
Option: Multiple options to increase availability,
competence, responsiveness and/or productivity
of rural health workers
Background
Problem: The poor access to skilled health workers in rural areas and the inequitable distribution of skilled health workers, within and between countries,
poses an important obstacle to the achievement of optimal attainable health for all. 1 The seriousness of the problem varies. However both developed and
developing countries report geographically skewed distributions of health workers, favouring urban and wealthy areas, despite the fact that people in rural
communities experience more health related problems.2 Lack of access to health workers is an important cause of health inequity.1
Approximately one half of the world's population lives in rural areas but these areas are served by only 38 percent of the total nursing workforce and by less
than 25 percent of the total physicians’ workforce (WHO, 2006). The problem is worst in low and middle income countries (LMIC) where the shortage of
trained health workers means an estimated one billion people have no access to essential health-care services.
Options: These recommendations relate to increasing the availability (quantity), competence (quality), responsiveness and productivity of all types of rural
health workers (including managers and support staff), within the boundaries of a country, using measures that improve the attractiveness of rural work, the
management of recruitment process, and the maintenance of the rural workforce. Multiple options have been suggested and are categorised as:
A. Education recommendations
B. Regulatory recommendations
C. A financial incentive recommendation
D. Personal and professional support recommendations.
These interventions may be more effective when implemented as bundles based on their complementarities, and on appropriate combinations for the
setting. Programmes can be designed by selecting one or more of the interventions recommended here, bearing in mind the local national health plan, the
existing health workforce and its management, and broader social, economic and political factors affecting the health workforce.
The evidence base for the recommendations: The WHO recommendations were developed following a review of all relevant and available evidence on
health workforce recruitment and retention in remote and rural areas, and have been informed by country experiences and expert judgements. Assessment
of the certainty of the evidence was done using GRADE. The certainty of the evidence for most interventions was assessed as low. Therefore, in deciding on
the strength of the recommendations, more weight has been given to other factors such as the balance between benefits and harms, the resources needed,
and the acceptability and feasibility of the interventions. Equity and the need for access to health care in rural areas were considered so important that
strong recommendations were still made even when the certainty of the evidence was low.
Setting: [Setting]
Add setting specific information to guide the choice of appropriate options for your context, for example: current levels, distribution and remuneration of
health workers by region and specialty; factors influencing health workers’ decisions about where to work; and social, economic and political factors that may
influence retention
HSPH EtD framework – multiple options (Version 2): Increasing rural access to health workers
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Problem: Poor access to skilled health workers in rural areas
OPTIONS
RECOMMENDATION
Option: Multiple options to increase availability, competence, responsiveness and/or productivity of rural health workers
JUSTIFICATION AND COMMENTS
Made by WHO
A1
A2
A3
A4
Targeted admission policies for
rural students to health worker
education programmes
Health worker schools outside
of major cities
Clinical rotations in rural areas
during studies
Curricula that reflect rural
health issues
Strong
recommendation
Conditional
recommendation
Conditional
recommendation
Strong
recommendation
Medical students from rural backgrounds are more likely to
practice in rural areas than students from urban backgrounds,
therefore increasing the rural availability of doctors. The impact
of rural background on the choice of rural practice in other
health cadres and in other settings is unclear.
Better results may be achieved by combining this intervention
with A2, A3 and/or B4
Link to framework A1
Graduates from rural medical schools or family medicine
residency programmes are more likely to practice in rural areas
than graduates from urban-based schools. Rural availability of
doctors is therefore increased. This needs to be weighed
against the costs of establishing, maintaining and staffing new
schools outside of urban areas. This option can be considered
when these factors are addressed.
Better results may be achieved by combining this intervention
with A1, A3 and/or A4
Link to framework A2
Undergraduate rural exposure may influence later choices to
practice rurally. Optional rural clinical rotations may ensure
students have appropriate skills and therefore improve
willingness to work rurally. Availability and competence of
health professionals may improve. However students who have
mandatory rotations in rural areas are not more likely to
practice in rural areas than students who do not.
Better results may be achieved by combining this intervention
with A1 and/or A2
Link to framework A3
Curricula that reflect rural health issues may ensure students
become more competent with appropriate skills for rural
practice.
Better results may be achieved by combining this intervention
with A2
Link to framework A4
HSPH EtD framework – multiple options (Version 2): Increasing rural access to health workers
CERTAINTY
OF THE
EVIDENCE
DECISION
(to be made)
COMMENTS ON THE DECISION
(to be made)
Full implementation
Impact evaluation
Moderate
Pilot study
[Additional information]
Postpone
Do not implement
Full implementation
Impact evaluation
Low
Pilot study
[Additional information]
Postpone
Do not implement
Full implementation
Impact evaluation
Very low
Pilot study
Postpone
Do not implement
Full implementation
Impact evaluation
Low
Pilot study
Postpone
Do not implement
2
Problem: Poor access to skilled health workers in rural areas
OPTIONS
RECOMMENDATION
Option: Multiple options to increase availability, competence, responsiveness and/or productivity of rural health workers
JUSTIFICATION AND COMMENTS
Made by WHO
A5
Continuing professional
development for rural health
workers
Conditional
recommendation
Continuing professional development for health professionals
practicing in rural areas can help ensure competence with
appropriates skills and may improve rural availability of health
workers through influencing the desire to remain in rural
practice.
Link to framework A5
HSPH EtD framework – multiple options (Version 2): Increasing rural access to health workers
CERTAINTY
OF THE
EVIDENCE
DECISION
(to be made)
COMMENTS ON THE DECISION
(to be made)
Full implementation
Impact evaluation
Low
Pilot study
Postpone
Do not implement
3
Problem: Poor access to skilled health workers in rural areas
Option: Multiple options to increase availability, competence, responsiveness and/or productivity of rural health workers
References
1
WHO 2010 Global policy recommendations:Increasing access to health workers in remote and rural areas through improved retention www.who.int/hrh/retention
Wilson NW, Couper ID, De Vries E, Reid S, Fish T, Marais BJ. A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas. Rural
and Remote Health 9: 1060. (Online), 2009 http://www.rrh
2
HSPH EtD framework – multiple options (Version 2): Increasing rural access to health workers
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Explanations
Explanations for Evidence to Decision Framework – Multiple options
We recommend the option
Recommendation symbols:
We suggest considering the option
We recommend against the option
Definitions for ratings of the certainty of the evidence (GRADE)1
Ratings
High
Moderate
Low
Very low
Definitions
Implications
This research provides a very good indication of the likely effect. The likelihood that the effect will
be substantially different2 is low.
This evidence provides a very good basis for making a decision about whether to implement the
intervention. Impact evaluation and monitoring of the impact are unlikely to be needed if it is
implemented.
This research provides a good indication of the likely effect. The likelihood that the effect will be
substantially different2 is moderate.
This evidence provides a good basis for making a decision about whether to implement the
intervention. Monitoring of the impact is likely to be needed and impact evaluation may be
warranted if it is implemented.
This research provides some indication of the likely effect. However, the likelihood that it will be
substantially different2 is high.
This evidence provides some basis for making a decision about whether to implement the
intervention. Impact evaluation is likely to be warranted if it is implemented.
This research does not provide a reliable indication of the likely effect. The likelihood that the effect
will be substantially different2 is very high.
This evidence does not provide a good basis for making a decision about whether to implement the
intervention. Impact evaluation is very likely to be warranted if it is implemented.
(Return)
The Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group began in the year 2000 as an informal collaboration of people with an interest in addressing the shortcomings of present grading
systems in health care. The working group has developed a common, sensible and transparent approach to grading quality of evidence and strength of recommendations. Many international organizations have provided input into the
development of the approach and have started using it.
1
2
Substantially different = large enough difference that it might have an effect on a decision
HSPH EtD framework – multiple options (Version 2): Increasing rural access to health workers
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