1| 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

2| Overview – developing the WHO recommendations Why guidelines? How did we go about it? What are the WHO recommendations?

3| 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

4| How did we go about it

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

6| 6 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

7| Category of interventionExamples 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

8| Education interventions: the rural pipeline Student selection: choosing the RIGHT PEOPLE targeting admission of students from a rural background (Sudan; Thailand) 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) Postgraduate training: creating the RIGHT OPPORTUNITIES Rural residency programmes (Sudan, Australia, Canada) Support of rural HCWs: nurturing the RIGHT ENVIRONMENT Career ladders for rural health workers (South Africa)

9| 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

10| Financial incentives: how much is "large enough"?

11| 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

12| Retention strategies – from planning to implementation, monitoring and evaluation Identify health service needs Labour market analysis Understanding preferences and health workers needs Situation analysis 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 Choosing the interventions: what criteria? Plan for it from the beginning Indicators: outcomes of interest, impact Methods and tools: capacity of health information systems Roles of stakeholders and partners Monitoring and evaluation

13| 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 Implementation: Human resources management systems Performance appraisal system, including awards Monitoring and evaluation: WHO framework: design, process, Indicators, outcomes of interest Roadmap and tools for implementation Source: Draft WHO/CapacityPlus/WB roadmap to support implementation of rural retention strategies

14| 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

15| Time to impact Category of intervention SHORT-TERMMEDIUM-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 service B4. 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 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

16| 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

17| A complex issue in a complex environment Management, environment and social support Direct and indirect financial incentives Education and regulatory interventions 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

18| Thank you for your attention! For further information, please contact Dr Carmen Dolea: