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.
Human Resources
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.
This qualitative paper reports on the experience of three community health worker (CHW) supervisors who were responsible for supporting infant feeding peer counsellors. The intervention took place in three diverse settings in South Africa. Each setting employed one CHW supervisor, each of whom was individually interviewed for this study. The study forms part of the process evaluation of a large-scale randomised controlled trial of infant feeding peer counselling support. The findings highlight the complexities of supervising and supporting CHWs. In order to facilitate effective infant feeding peer counselling, supervisors in this study had to move beyond mere technical management of the intervention to broader people management. While their capacity to achieve this was based on their own prior experience, it was enhanced through being supported themselves. In turn, resource limitations and concerns over safety and being in a rural setting were raised as some of the challenges to supervision. Adding to the complexity was the issue of HIV. Supervisors not only had to support CHWs in their attempts to offer peer counselling to mothers who were potentially HIV positive, but they also had to deal with supporting HIV-positive peer counsellors. This study highlights the need to pay attention to the experiences of supervisors so as to better understand the components of supervision in the field.
Durban health workers who treat patients with drug-resistant TB are noted to face increase risk of drug resistant TB. According to Dr Iqbal Master, head of clinical services at King George V Hospital in Durban, the province’s specialist hospital for drug-resistant TB, they should be given special incentives to recognise this. King George V Hospital has been trying to get itself declared 'inhospitable', which would mean that staff would get additional incentives for this. Workers at the facility are reported to be six times more likely to get drug-resistant TB than ordinary members of the public. In the last decade, 14 staff members are reported to have died of the TB and one staff member was being treated for drug-resistant (XDR) TB.
This study evaluated two models of routine HIV testing of hospitalised children in a high HIV-prevalence resource-constrained African setting. Both models incorporated task shifting, namely the allocation of tasks to the least-costly, capable health worker. Two models were piloted for three months each within the paediatric department of a referral hospital in Lilongwe, Malawi between January 1 and June 30, 2008. Model 1 utilised lay counsellors for HIV testing instead of nurses and clinicians, while Model 2 further shifted programme flow and advocacy responsibilities from counsellors to volunteer parents of HIV-infected children, called 'patient escorts'. The strategy presented here in the two models, namely task shifting from lay counsellors alone to lay counsellors and patient escorts, was found to improve programme outcomes greatly, while only marginally increasing operational costs. The wider implementation of this strategy could accelerate paediatric HIV care access in high-prevalence settings.