WHO Recommendations to improve retention of rural and remote health workers - important for all countries

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The World Health Organization 2010 Global Policy Recommendations: 'Increasing Access to Health Workers in Remote and Rural Areas through Improved Retention' is a notable milestone in rural health policy¹. This report, with preface by WHO Director General Dr. Margaret Chan, recognizes at the very highest level that the half of the world's population that lives in rural and remote areas faces enormous difficulties in accessing appropriate and equitable health care.

A shortage of qualified health workers in rural and remote areas impedes access to health-care services for a significant percentage of the population, slows growth towards attaining the Millennium Development Goals and challenges the aspiration of achieving health for all.¹

The WHO includes in this shortage, doctors, nurses, midwives, mid-level health workers, pharmacists, dentists, laboratory technicians and community health workers, as well as managers and support workers. This shortage of qualified rural health workers is found almost in all countries but its impact is felt most severely by the poorest people in the least developed regions. In contrast, most of the world's health workers grew up and were educated, live and work in large cities.

The past 30 years has seen increasing recognition of both poor health status and barriers to care for rural people as well as the development of some innovative rural health care programs and policies. The WHO has sifted through the growing body of literature to develop comprehensive, evidence-informed recommendations for education, regulation, financial incentives, as well as personal and professional support for rural health workers (Fig1). A one-page detailed analysis is provided for each of the recommendations outlining the quality of the evidence (ranges from 'very low' to 'moderate'), magnitude of effect, benefits versus disadvantages, resource use and feasibility. The recommendations vary from 'conditional' to 'strong'.

Many of the outcomes reported in the literature, however, have multi-factorial causes that cannot be so easily separated out. For example, the medical schools that produce the most rural physicians most often have in common, location in a rural region, a high proportion of students admitted to the medical school from rural areas, a comprehensive rural experiential-focused learning within a strong and well-supported rural education network, most often in a safe region/country with a strong positive rural regulatory approach with favorable financial incentives and strong personal and professional support^2,3.

Figure 1: WHO Recommendations to improve attraction, recruitment and retention of health workers in remote and rural areas¹.

All countries need health workers who can live and work effectively in rural areas. The literature from studies in several countries strongly shows that health workers who grew up in rural areas are much more likely to become rural health workers than those with an urban background. Nevertheless, some people growing up in cities can become very committed rural health workers, particularly those with a spirit of adventure, a rural experience in their education and the development of an appropriate skill set. To be effective, rural health care workers need to be part of a rural and regional healthcare team. Providing appropriate facilities and supports both improves the recruitment and retention of healthcare workers and improves their effectiveness and efficiency.

The choice to live and work in rural areas is complex and attention needs to be paid to both personal and professional factors⁴. Personal and family safety and accommodation, education, social and recreational opportunities play a big role in decisions to come to and/or leave rural communities. The realities of rural health practice are often challenging but interesting, and the work difficult but highly rewarding. Rural practitioners often need a broader and deeper skill set to be able to deal with emergencies and other complex patient care services that in larger urban centers are often looked after by a team of specialists. Workload can be heavy, often including night and weekend on-call. Financial incentives need to recognize and reward these challenges of living and working in rural and remote areas. Compulsory rural return-of-service may have a limited effect but does not work well as a stand-alone policy substituting in place of addressing the major recruitment and retention factors.

The WHO realistically notes that a 'cookie-cutter' approach 'applying so-called "best practices" from one country to another will not work without a clear understanding of the specific situation, needs and context'¹. This report highlights the importance of ensuring rural health workforce retention policies are part of national health plans. It recognizes 'that every government influences the health labor market through regulation, finance and information', noting that 'an entirely free labor market will never lead to a well-distributed health workforce because so many people are drawn to urban centers or in some cases, other countries'¹. The issues around recruitment of rural health workers by other countries is further addressed by the WHO Global Code of Practice on the International Recruitment of Health Personnel, adopted in May 2010 at the 63rd World Health Assembly⁵.

In summary, this report provides a systematic analysis of the research on the education, recruitment and retention of rural health workers with carefully constructed, evidence-informed recommendations. With this report, the WHO is indicating that rural health is important, and its serious recommendations will contribute substantially to the goal of improved health for all rural peoples.

James Rourke
Dean, Faculty of Medicine,
Memorial University of Newfoundland
Newfoundland, Canada

Editor's note: Readers may also access a Rural and Remote Health book review of the Guidelines⁶.

References

1. WHO. The World Health Organization 2010 Global Policy Recommendations - Increasing access to health workers in remote and rural areas through improved retention. Geneva: WHO, 2010.

2. Rourke J. How can medical schools contribute to the education, recruitment and retention of rural physicians in their region? Bulletin World Health Organization 2010; 88(5): 395-396.

3. Curran V, Rourke J. The role of medical education in the recruitment and retention of rural physicians. Medical Teacher 2004; 26(3): 265-272.

4. Rourke J. Increasing the number of rural physicians. Canadian Medical Association Journal 2008; 178(3): 322-325.

5. WHO. World Health Organization Global Code of Practice on the International Recruitment of Health Personnel. Geneva: WHO, 2010.

6. Lopez-Abuin J. Review of: 'Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations: Global policy recommendations'. Rural and Remote Health 10(4): 1647. (Online) 2010. Available: www.rrh.org.au (Accessed 24 November 2010).