Retention of health workers with a focus on rural areas
WHO-OECD hosted dialogue on migration and other health workforce issues in a global economy Geneva, 20-21 October 2008
Pascal Zurn Department of Human Resources for Health World Health Organization, Geneva
1 | WHO-OECD hosted dialogue on migration and other health workforce issues in a global economy | Geneva, 20-21 October Health Workforce: Geographical Imbalance z Rural areas comprise a large share of the world population but a small share of the health workforce
Population Physicians
Percentage of Percentage of Percentage of physicians in physicians in population living urban areas rural areas in rural areas 76% 24% Percentage of 52% population living in urban areas 48%
Source: WHO, 2006; UN, 2004 z Remote/isolated and sometimes suburbs or inner cities are also underserved areas
2 | WHO-OECD hosted dialogue on migration and other health workforce issues in a global economy | Geneva, 20-21 October Health Workforce Retention: a Global Concern (1/2) z Retention is a concern in all countries… – Higher or lower income countries France: General Practitioner density – Large or small countries
Niger: Physician density
Niamey Agades Diffa GP density per Zinder GP density per 10001,000 pop pop Maradi Less than 1.43 Tillaberi 1.43 - 1.54 Dosso 1.54 - 1.67 Tahoua 1.67-1.84 1.84 and more 0.0 0.5 1.0 1.5 2.0 2.5 Physicians per 10,000 pop
3 | WHO-OECD hosted dialogue on migration and other health workforce issues in a global economy | Geneva, 20-21 October Health Workforce Retention: a Global Concern (2/2)
Senegal: Nurse density z …and for all health occupations Ziguinchor – Doctors Dakar – Nurses/Midwives Matam Tamba – Pharmacists St-Louis Fatick – Dentists Thies – Health associate professions Kaolack Louga Kolda Canada: Nurse and Physicians density Diourbel
0.00 0.10 0.20 0.30 0.40 0.50 0.60 New Foundland and Labrador Nurses per 10000 pop Prince Edward Island Source: Zurn et al. 2008 New Brunswick Manitoba Nova Scotia Saskatchewan Quebec Alberta Ontario British Columbia
024681012 Nurses and physicians per 1000 pop Dumont al. 2008
4 | WHO-OECD hosted dialogue on migration and other health workforce issues in a global economy | Geneva, 20-21 October Underserved Areas and Health System Performance z Health professionals and the z The case of Senegal coverage of births by skilled birth 100%
attendants 90% – Regions with lower health 80% 70% professionals density tend to have a 60% 50%
lower coverage of births by skilled attendants (%) 40% birth attendants 30% 20% – Poorer regions tend to have a lower birth skilled by births of Coverage 10% 0% density of health workers and a 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 1.80 doctors, nurses and midwives per 1000 population lower coverage of births by skilled birth attendants – Inequality and inequity in health workforce distribution
5 | WHO-OECD hosted dialogue on migration and other health workforce issues in a global economy | Geneva, 20-21 October Improving Retention in Rural Areas z Factors affecting the decision z Working in rural areas in Niger: to go to or stay in rural areas: Health professionals expectations
Continuous education
– Personal factors Medical and technical devices
Better amenity
– Professional environment Availability of drugs
Remuneration 2008 Housing – Social and local environment 2005 Undertake applied research
Access to specializsation training
Job security
Spouse employment
Children Education
0% 20% 40% 60% 80% 100% Source: Sedes, 2008
6 | WHO-OECD hosted dialogue on migration and other health workforce issues in a global economy | Geneva, 20-21 October Policies to Improve Retention in Rural Areas (1/2) z A large range of policies and initiatives have been developed
– Education related measures ¾ Student enrolment ¾ Rural training/placement ¾ Return of service
– Regulatory measures ¾ Bonding schemes ¾ Provisional licence
– Financial incentives ¾ Remuneration (mode and level) ¾ Special allowances ¾ Pension
7 | WHO-OECD hosted dialogue on migration and other health workforce issues in a global economy | Geneva, 20-21 October Policies to Improve Retention in Rural Areas (2/2)
– Improving working conditions ¾ Career development ¾ Support for training ¾ Network support/multidisciplinary health centres ¾ Provision of adequate equipment ¾ Security
– Creating different types of cadres (substitution, task shifting)
– Improving living conditions ¾ Housing ¾ School for children ¾ Transportation ¾ Communication
– Community initiatives ¾ Integration in the community (for the health worker, spouse and children)
8 | WHO-OECD hosted dialogue on migration and other health workforce issues in a global economy | Geneva, 20-21 October Key elements z Retention in rural areas is a complex issue but essential to address z Most policies are based on financial incentives z No "single bullet" but a mix of solutions adapted to each specific context z Importance of intersectoral approach
9 | WHO-OECD hosted dialogue on migration and other health workforce issues in a global economy | Geneva, 20-21 October Selected Issues - Perspectives z Evaluation of policies z Identification of most promising policies z Sustainability of policies z A global strategy for improving retention
10 | WHO-OECD hosted dialogue on migration and other health workforce issues in a global economy | Geneva, 20-21 October Selected Issues - Perspectives z A WHO programme for increasing access to health workers in rural areas through improved retention strategies
– Building and sharing evidence based good practices
– Supporting countries
– Developing and disseminating global policy recommendations
11 | WHO-OECD hosted dialogue on migration and other health workforce issues in a global economy | Geneva, 20-21 October WHO's programme of work: process to develop guidelines and recommendations for retention of health workers
Mar08 April08 May08 June08 July08 Sept08 Oct08 Nov08-Mar09 Apr-Sept09 Oct-Dec09
Additional research in Clarification Senegal Kampala countries of needs and case study Forum scope Development of Country case studies: Initial partnerships and UAE, Caribbean, consultations technical Philippines Evidence gathering collaboration literature reviews, Mali case - methodology Regional and country expert opinion study consultations, drafting meeting - identification of and reviewing the evidence gaps WHO-OECD guidelines Policy Production of guidelines dialogue and recommendations
Technical brief on scope and the process for the guidelines Guidelines for retention of health workers
12 | WHO-OECD hosted dialogue on migration and other health workforce issues in a global economy | Geneva, 20-21 October