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With increasing interest in the ethical recruitment of internationally trained health professionals to developed countries, it is necessary to pay equal attention to the ethical questions that arise related to recruitment and retention of health professionals to regional, rural and remote areas (subsequently referred to as rural). Given the recognized shortage of health professionals in rural areas, government and community strategies are being developed to address this need. While there is an abundance of literature examining the effectiveness of various recruitment and/or retention strategies to these areas, there is surprisingly little literature that asks critical questions about the ethical dimensions of these strategies1,2. Policies and practices are not value neutral; all have a moral dimension which should be explored. Taking a closer look at these strategies is important as they reflect what societies, communities and individuals, value and how these values are put into practice. It also enables us to examine the possible long-term consequences of such policies and practices.
Before proceeding with the analysis, readers are advised of some things this article will not address. First, while there may be ethics issues specific to either recruitment or retention, for the purposes of this article these are considered together as the issues discussed below are applicable to both. Second, although an additional layer of ethical issues arises with the recruitment and/or retention of internationally trained health professionals, this issue will not be addressed specifically. Third, the focus is primarily on examining issues related to recruitment and/or retention, not the prior 'priming' work that is undertaken by, for example, exposing health professionals in training to rural communities/practice. Fourth, it is recognized that there are a multiplicity of definitions as to what constitutes 'rural' and the specifics of the analysis may apply differentially across different contexts3. It is the intention of this article to outline a conceptual framework for ethical analysis which can be utilized in a variety of practice settings, regardless of how the particular context is defined.
An overview and discussion will be provided of a series of ethics issues and questions related to rural recruitment and/or retention of health professionals at the macro (health system/government), meso (community), and micro (individual health professional) levels. A comprehensive analysis of each level and the interrelationships between these levels is required, if the degree to which each contributes to creating the conditions under which health professionals are recruited, and the terms upon which they stay in rural areas, are to be fully appreciated. This analysis highlights the importance of managing trust relationships and the impact of power imbalances and vulnerabilities as part of processes for recruitment and retention.
Literature was identified (including grey literature, eg reports) that discusses the recruitment and/or retention of health professionals to rural areas. It was noteworthy that few explicitly discussed the ethical dimensions of this issue. Attention was focused on these papers, as well as those that, in the authors' view, implicitly raised ethics issues related to recruitment and/or retention. From these papers, both authors further identified elements of the recruitment and/or retention strategies that have been employed and organised them in respect of levels of governance (namely, the levels of health system/government, community, and individual health professionals). Early on, it was identified that each of these three levels was critical to address the broader issue as each level is a key stakeholder in the processes of recruitment and retention, yet it does not appear that a comprehensive analysis across all levels has been undertaken. These elements were subjected to analysis to assess their ethical dimensions and to determine whether a clash or complement of values arises at each level of governance or between governance levels4. Accordingly, the ethical analysis undertaken in this article draws from a variety of ethical approaches, recognizing that one ethical approach is necessarily limited in its scope, to identify and assess the values that are implicit or explicit in policies and practices in this area. An ethical analysis can assist in establishing the basis of a broader and more stable process for public policy, that is, recruitment and/or retention, as well as the continual clarification of its relevant goals and purposes4. As such, the values analysis critiques the existing social practices of rural recruitment and retention to examine normative concerns related to power, trust and vulnerability; values, as demonstrated below, of particular relevance for this work.
Recruitment and/or retention processes are discussed in the literature but predominantly in the context of what mechanisms have been effective in recruiting and retaining health professionals in rural areas. There is very little literature in this area that considers the ethical dimensions of recruitment and/or retention processes and none from a health policy ethics perspective1,2. There is also little literature taking a comprehensive view of the connections and interrelationships between the different levels and stakeholders engaged in the process. Yet policies and practices are not value neutral and all have a moral dimension4.
Discussion
Macro level
The allocation of health-related resources, including health professionals, to rural communities raises important ethical questions, particularly given the measurable gaps in health outcomes between rural and urban populations and the difficulties some rural areas face in accessing necessary health services5,6. The recognition of these challenges has been important to motivating action at the national and/or state/provincial government level, that is, through the development of policies and strategies to help bridge these gaps. The importance of addressing these gaps in outcomes and service provision is not downplayed, but raised here are three issues, among others, that deserve further examination from the perspective of developing 'good' rural recruitment and/or retention policies.
First, a cautionary note is sounded about the potential, problematic implications from an ethical perspective of an overemphasis on the 'deficit' perspective of rural health and the ways in which this may overly influence or determine - in potentially negative ways - rural recruitment and/or retention policies. For example, as Bourke et al have suggested, the deficit model has led, in part, to an understanding of rural communities as 'problematic environments in which to work'3. The extent to which this perspective is embedded within recruitment and/or retention policies legitimizes a sense that the recruitment and/or retention of health professionals to rural areas is a problem in need of remedial solutions. From an ethical perspective this is potentially problematic as it may foster the sense that rural communities can expect 'second-class' services or band-aid solutions that address, at least in part, the short-term need to get a health professional into a community but ignore both the implications of this for the provision of effective health services to a community and the long-term issues of sustainability. Such an approach also essentially ignores the potential strengths of rural practice which could be leveraged to advantage within recruitment and/or retention policies.
An overly heavy focus on a deficit approach may also influence the degree to which all actors in this process could be asked to 'sell their soul' in order to, as one community put it: 'if we can get one back here, it's worth it...'7. This highlights questions of vulnerability and the relative power imbalances between stakeholders (eg government versus rural communities vs health professionals). Further, the deficit perspective, in combination with the structure of healthcare systems in developed nations, may reinforce a paradigm in which health professionals are accorded differing levels of value (eg doctors are 'worth more' or are a greater priority than other health professionals)8. This may then be reflected in recruitment and/or retention measures, such as monetary incentives, used in rural areas, thereby reinforcing entrenched, problematic differentials in power and hierarchy.
Second, thinking about the viability and sustainability of our healthcare systems, the ethical values of trust and collaboration are significant2. The functioning of the health system is dependent on its components working well together. As such, active competition between stakeholders has the potential to undermine the integrity of the system illustrating that there often is a tension between competing and collaborating in the context of scarce resources. This is where concerns about 'poaching' arise in recruitment and/or retention processes. 'Poaching' refers to one component of the health system enticing health professionals to move from another component, thereby potentially weakening the latter's capacity to provide health services9. While most often viewed in a global context, poaching may also occur within countries, between urban and rural communities or across different regions. These activities have implications in respect of the degree of trust that may be maintained between institutions and communities, and their ability to collaborate with each other to optimise rural health outcomes. Policies set at a government level may either increase or decrease the degree to which poaching is seen to be an acceptable approach for recruitment and/or retention, and need to be reviewed through this lens.
Third, the distribution of health professionals matters on a number of levels. However, it is unclear what an appropriate distribution between urban and rural, and within rural, settings should be and who determines what this is. Appropriate measures of success relative to recruitment and/or retention still need to be established, as one mechanism for evaluating the effects of health professional movement5,6,10. Effectiveness, in terms of getting a health professional into a rural community and having them stay for a certain (varying) length of years is a commonly used measure. However, from an ethical perspective it is suggested that such measures may need to look beyond getting health professionals to a community and having them stay for a period of time (an instrumental measure), to also examine the health and social outcomes for communities in which those health professionals are based (appreciating this is affected by more than the presence of health care providers). As such, these are not just issues to be addressed at the macro level, but are ones also faced by rural communities as they jointly participate in recruitment and/or retention processes.
Meso level
In response to the need for health professionals, a number of rural communities are actively engaged in recruitment and/or retention activities. This raises ethical questions about their roles and responsibilities vis-à-vis government actors. Is this a problem in which governments should be expected to take the lead given that they generally generate rural health policy and fund, for the most part, rural health services? Or is it largely a community responsibility given that the evidence, such as it is, indicates community involvement improves the effectiveness/success of recruitment and/or retention processes5,10? From an ethical perspective, community involvement in matters that fundamentally affect the delivery of health services at a local level is desirable and appropriate. Rather than having strategies imposed from the outside, (community) stakeholder participation needs to be valued. A stakeholder approach engages those affected by public healthcare policy, demonstrating respect for these communities and individuals and fulfilling expectations of participatory democracy. In turn, if this is what is valued, questions about what is meant by community involvement need to be addressed. Who should be involved? Whose voices are heard and about what? How should disagreements between macro and meso level concerns and within the meso level (eg what is the recruitment and/or retention priority for this community) be resolved? Also what of the community itself? Cultural differences, for example between indigenous communities and other stakeholders, may exacerbate power differentials between stakeholders in the recruitment/retention processes.
It is suggested that it is particularly important for rural communities to discuss their expectations of health professionals, in terms of community expectations about their practice and role within the community, because of the nature of rural practice. Clarity around the incoming health professionals' work-life balance and whether health professionals are expected to be leaders in the community are two examples of potential exploitation of health professionals by communities. A further condition for exploitation may be the overselling of a 'lifestyle' choice for practice; communities should consider the ethics of fairly representing who they are, lest they be accused of deceptive practices which undermine the trust relationship between communities and health professionals. With respect to retention, it is suggested that communities need to attend to their undertakings with respect to the level of support provided for health professionals, the degree of autonomy in their practice, and inclusiveness within the community11. It is also important that communities discuss what their expectations of community members are, as recruitment and/or retention processes have the potential to create tensions within communities and/or exacerbate already existing fractures. These tensions and fractures can become more apparent in rural communities given their relative size and degree of overlapping and multiple relationships. Alternatively, involvement in these processes can further strengthen a strong community or serve as unifying factors that bring community members together. Ultimately, openness to discussing the potential differential impacts of community engagement on that community should be part of recruitment and/or retention processes.
Micro level
As discussed above, health professionals also play an integral part in recruitment and retention processes. As they participate in recruitment and/or retention processes, health professionals need to balance a number of potentially competing interests, including the need to make a living, pay off any education debts, get their first job, and maintain their professionalism and integrity. The authors' view is that professionalism and integrity require health professionals to act in ways consistent with the values of their respective profession. When contemplating recruitment, health professionals should reflect deeply on the conditions of rural practice and the implications of accepting any incentives. There is a relative power imbalance between health professionals, employers (whether they be national, state/provincial or local) and rural communities, which creates particular vulnerabilities, in recruitment and/or retention processes. Relatively speaking, rural communities have to invest more than those in urban settings in recruitment and/or retention. With the shortage of health professionals in rural settings, and communities competing against each other for this scarce resource, it is possible for health professionals to take advantage of the situation and exploit 'desperate' communities. While these issues arise in urban settings too, the inherent vulnerabilities of rural communities stress the importance of health professionals considering the effects of their choices on the community.
One key reflection point should be whether one is choosing to practice in a rural area for the 'right' reasons. To clarify, a value judgment is not being made about accepting any incentives offered as part of recruitment; it is recognized that health professionals have a legitimate interest in appropriate levels of remuneration. Likewise, there are good reasons why health professionals may choose different lengths of time to stay with specific communities. Traditionally communities have had expectations that health professionals would stay for a 'lifetime'; this has been challenged over the last 20 years with changing societal norms about work. Research has demonstrated that health professionals emerging from Generation Y are likely to be even more transient12. The question of interest is the degree to which the health professional is prepared to give back to the community while he/she practices there. How should a health professional propose to negotiate challenges that may arise in the context of rural practice, such as the potential loss of privacy, work-life balance, and expected engagement with the community13? Further, if a health professional only plans to stay for a few years, should he/she, out of respect for the community, be honest about her intentions? Otherwise, is the health professional exploiting their goodwill?
Fundamentally, these questions are about the nature of the relationship between a health professional and the community. It has long been recognized that trust is a cornerstone of relationships between patients and health professionals and equally between the public and health professionals. If a health professional does not openly communicate with the community about his/her intentions, needs and expectations, she could unintentionally, intentionally or unthinkingly mislead the community and undermine trust. Any damage to this relationship not only affects the community's ability to trust that individual, but also their ability to trust other health professionals.
As this overview indicates, there is more to consider with respect to rural recruitment and/or retention strategies than whether they are effective. Using an ethics perspective, in particular a values analysis, provides a deeper appreciation of the issues confronting all stakeholders involved in these processes. By analyzing the issues at three levels (macro, meso, and micro), a number of cross-cutting themes are identified, namely issues of managing trust relationships and power imbalances, and negotiating vulnerabilities. It also illustrates that, at times, actors will compete against each other and there will sometimes be a critical conflict between values; for example, competition and collaboration can be antithetical. These themes are important factors that underlie recruitment and/or retention strategies, illustrating why it is so important that all stakeholders are cognizant of the underlying interests. As part of developing recruitment and/or retention strategies, all must therefore carefully consider how their values impact the decisions that are made and the consequent outcomes.
Finally, it is recognized that the specific ethical issues surrounding rural recruitment and/or retention require further analysis, not just by ethicists but also by those involved in these processes. In an environment where recruitment and/or retention of health professionals is increasingly challenging, there may be pressure to overlook, ignore and/or understate the importance of these issues in the interests of a short-term fix, that is, filling a vacant position. How we collectively respond will shape the face of rural health care for decades to come.
Acknowledgment
The authors gratefully acknowledge the helpful comments received from Lori d'Agincourt-Canning and Christina Holmes on an earlier version of this manuscript.
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