This resolution of the 63rd World Health Assembly outlines a set of standards for the international recruitment of health personnel. The code of practice aims to establish and promote voluntary principles and practices for the ethical international recruitment of health personnel. It provides member states with ethical principles for international health worker recruitment that strengthen the health systems of developing countries. It discourages states from actively recruiting health personnel from developing countries that face critical shortages of health workers, and encourages them to facilitate the 'circular migration of health personnel' to maximise skills and knowledge sharing. It enshrines equal rights of both migrant and non-migrant health workers. The code sets the provisions for member states to monitor and report on the implementation of the code, for reporting back to the Assembly in 2012.
Human Resources
This review provides a comprehensive overview of the most important studies addressing the recruitment and retention of doctors to rural and remote areas. A comprehensive search of the English literature was conducted using the National Library of Medicine’s (PubMed) database and a total of 110 articles were included. The available evidence was classified into five intervention categories: selection, education, coercion, incentives and support. The main definitions used to define ‘rural and/or remote’ in the articles reviewed were summarised before the evidence in support of each of the five intervention categories was presented. The review argues for the formulation of universal definitions to assist study comparison and future collaborative research. Although coercive strategies address short-term recruitment needs, little evidence supports their long-term positive impact. Current evidence only supports the implementation of well-defined selection and education policies, although incentive and support schemes may have value. The review concludes that the impact of untested interventions needs to be evaluated in a scientifically rigorous fashion to identify winning strategies for guiding future practice and policy.
Compulsory service programmes have been used worldwide as a way to deploy and retain a professional health workforce within countries. Other names for these programmes include 'obligatory', 'mandatory', 'required' and 'requisite.' All these different programme names refer to a country’s law or policy that governs the mandatory deployment and retention of a heath worker in the underserved and/or rural areas of the country for a certain period of time. This study identified three different types of compulsory service programmes in 70 countries. These programmes are all governed by some type of regulation, ranging from a parliamentary law to a policy within the ministry of health. Depending on the country, doctors, nurses, midwives and all types of professional allied health workers are required to participate in the programme. Some of the compliance-enforcement measures include withholding full registration until obligations are completed, withholding degree and salary, or imposing large fines. This paper aims to explain these programmes more clearly, to identify countries that have or had such programmes, to develop a typology for the different kinds and to discuss the programmes in the light of important issues that are related to policy concepts and implementation. As governments consider the cost of investment in health professionals’ education, the loss of health professionals to emigration and the lack of health workers in many geographic areas, they are using compulsory service requirements as a way to deploy and retain the health workforce.
The lack of health workers in remote and rural areas is a worldwide concern. Many countries have proposed and implemented interventions to address this issue, but very little is known about the effectiveness of such interventions and their sustainability in the long run. This paper provides an analysis of the effectiveness of interventions to attract and retain health workers in remote and rural areas from an impact evaluation perspective. It reports on a literature review of studies that have conducted evaluations of such interventions. It presents a synthesis of the indicators and methods used to measure the effects of rural retention interventions against several policy dimensions such as: attractiveness of rural or remote areas, deployment/recruitment, retention, and health workforce and health systems performance. It also discusses the quality of the current evidence on evaluation studies and emphasises the need for more thorough evaluations to support policy-makers in developing, implementing and evaluating effective interventions to increase availability of health workers in underserved areas and ultimately contribute to reaching the United Nations' Millennium Development Goals.
Many countries have developed strategies to attract and retain qualified health workers in underserved areas, but there is only scarce and weak evidence on their successes or failures. It is difficult to compare lessons and measure results from the few evaluations that are available. Evaluation faces several challenges, including the heterogeneity of the terminology, the complexity of the interventions, the difficulty of assessing the influence of contextual factors, the lack of baseline information, and the need for multi-method and multi-disciplinary approaches for monitoring and evaluation. Moreover, the social, political and economic context in which interventions are designed and implemented is rarely considered in monitoring and evaluating interventions for human resources for health. This paper proposes a conceptual framework that offers a model for monitoring and evaluation of retention interventions taking into account such challenges. The conceptual framework is based on a systems approach and aims to guide the thinking in evaluating an intervention to increase access to health workers in underserved areas, from its design phase through to its results. It also aims to guide the monitoring of interventions through the routine collection of a set of indicators, applicable to the specific context. It suggests that a comprehensive approach needs to be used for the design, implementation, monitoring, evaluation and review of the interventions. The framework is not intended to be prescriptive and can be applied flexibly to each country context. It promotes the use of a common understanding on how attraction and retention interventions work, using a systems perspective.
This policy brief notes that a significant share of health worker migration is occurring between Organization for Economic Co-operation and Development (OECD) countries, even though the bulk of migration flows is originating from developing and emerging countries. Countries with expatriation rates of doctors above 50% (which means that there are as many doctors born in these countries working in the OECD countries as there are working in their home country) include five African countries: Mozambique, Angola, Sierra Leone, Tanzania and Liberia. The brief found that the needs for health workers in developing countries, as estimated by the World Health Organization (WHO), largely outstrip the numbers of immigrant health workers from those countries working in OECD countries. In 2000, all African-born doctors and nurses working in the OECD represented no more than 12% of the total shortage for the region, as estimated by WHO. The brief argues that international migration is neither the main cause of healthcare shortages in developing countries, nor would its reduction be enough to address to the worldwide health human resources crisis. It recommends that receiving countries should expand education and training capacity to reduce dependency on foreign health personnel to fill domestic needs.
The authors of this paper undertook a systematic review to consolidate existing evidence on the impact of financial and non-financial incentives on health worker motivation and retention. They searched four literature databases, as well as Google Scholar and the journal, Human Resources for Health. Grey literature studies and informational papers were also captured. Twenty articles met the inclusion criteria, consisting of a mix of qualitative and quantitative studies. Seven major motivational themes were identified: financial rewards, career development, continuing education, hospital infrastructure, resource availability, hospital management and recognition/appreciation. There was some evidence to suggest that the use of initiatives to improve motivation had been effective in helping retention, but less clear evidence on the differential response of different cadres. While motivational factors are undoubtedly country specific, the authors identified financial incentives, career development and management issues as core factors. The authors concluded that financial incentives alone are not enough to motivate health workers, that recognition is highly influential in health worker motivation and that adequate resources and appropriate infrastructure can improve morale significantly.
The National Institutes of Health has announced a new initiative to strengthen medical education in sub-Saharan Africa, in collaboration with the President’s Emergency Plan for AIDS Relief (PEPFAR). The programme, called the Medical Education Partnership Initiative, is a joint effort of the Office of the United States Global AIDS Coordinator, the Health Resources and Services Administration, the Centres for Disease Control and Prevention, the United States Department of Defense and 19 components of NIH. This programme is in support of PEPFAR's goal to increase the number of new health care workers by 140,000, and will also serve the related objectives of strengthening host-country medical education systems and enhancing clinical and research capacity in Africa. Foreign institutions and their partners in PEPFAR-supported Sub-Saharan African countries are invited to submit proposals to develop or expand models of medical education. These models are intended to contribute to the sustainability of country HIV and AIDS responses by expanding the pool of well-trained clinicians. The awards will also build the capacity of local scientists and health care workers to conduct multidisciplinary research, so that discoveries can more effectively be adapted and implemented in their communities and countries. Nine programmatic awards are available.
This study aimed to evaluate the relative effectiveness of different policies in attracting nurses to rural areas in Kenya, South Africa and Thailand using data from a discrete choice experiment (DCE). A labelled DCE was designed to model the relative effectiveness of both financial and non-financial strategies designed to attract nurses to rural areas. Data were collected from over 300 graduating nursing students in each country. Mixed logit models were used for analysis and to predict the uptake of rural posts under different incentive combinations. The study found that nurses’ preferences for different human resource policy interventions varied significantly between the three countries. In Kenya and South Africa, better educational opportunities or rural allowances would be most effective in increasing the uptake of rural posts, while in Thailand better health insurance coverage would have the greatest impact. In conclusion, it recommends that DCEs can be designed to help policy-makers choose more effective interventions to address staff shortages in rural areas. Intervention packages tailored to local conditions are more likely to be effective than standardised global approaches.
This study conducted a systematic literature review of task shifting and found 2,960 articles, of which 84 were included in the core review. Fifty-one articles reported outcomes, including research from ten countries in sub-Saharan Africa. The most common type of task shifting studied was the delegation of tasks from doctors to nurses and other non-physician clinicians, especially initiating and monitoring highly active anti-retroviral therapy (HAART). Five studies showed increased access to HAART through expanded clinical capacity; four concluded task shifting is cost effective; nine showed staff could deliver equal or better quality of care; and studies on whether non-physicians and physicians were in agreement with their clinical decisions offered mixed results, with most showing good agreement. The study argues that task shifting is an effective strategy for addressing shortages of health workers in HIV treatment and care and believes it offers high-quality, cost-effective care to more patients than a physician-centered model could. The main challenges to implementation include adequate and sustainable training, support and pay for staff in new roles, the integration of new members into healthcare teams, and the compliance of regulatory bodies. The study recommends that task shifting should be considered for careful implementation where health worker shortages threaten rollout programmes.