ORIGINAL RESEARCH Retention of qualified healthcare workers in rural Senegal: lessons learned from a qualitative study M Nagai 1, N Fujita 1, IS Diouf 2, M Salla 2 1Division of Global Health Programs, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Shinjuku-ku, Tokyo, Japan 2Department of Human Resources, Ministry of Health and Social Actions, Dakar, Senegal Submitted: 20 July 2016; Revised: 18 April 2017, Accepted: 19 April 2017; Published: 12 September 2017 Nagai M, Fujita N, Diouf IS, Salla M Retention of qualified healthcare workers in rural Senegal: lessons learned from a qualitative study Rural and Remote Health 17: 4149. (Online) 2017 Available: http://www.rrh.org.au A B S T R A C T Introduction: Deployment and retention of a sufficient number of skilled and motivated human resources for health (HRH) at the right place and at the right time are critical to ensure people’s right to access a universal quality of health care. Vision Tokyo 2010 Network, an international network of HRH managers at the ministry of health (MoH) level in nine Francophone African countries, identified maldistribution of a limited number of healthcare personnel and their retention in rural areas as overarching problems in the member countries. The network conducted this study in Senegal to identify the determining factors for the retention of qualified HRH in rural areas, and to explore an effective and feasible policy that the MoH could implement in the member countries. Methods: Doctors, nurses, midwives and superior technicians in anesthesiology who were currently working (1) in a rural area and had been for more than 2 years, (2) in Dakar with experience of working in a rural area or (3) in Dakar without any prior experience working in a rural area were interviewed about their willingness and reasons for accepting work or continuing to work in a rural area and their suggested policies for deployment and retention of healthcare workers in rural areas. In-depth interviews were conducted with policy makers in MoH, asking for their perceptions on human resource management in health and about their suggested policies for deployment and retention. Results: A total of 176 healthcare workers and eight policy makers were interviewed. The willingness to face challenges in a new place was one of the main reasons for accepting work in rural areas. The identified factors to motivate or demotivate healthcare workers in rural areas were related to pre-service and in-service education, regulatory systems, financial and non-financial incentive schemes and environmental support. Factors not included in WHO’s global recommendation but highly valued in this study were (1) the fairness, transparency and predictability of human resource management by the MoH and (2) employment status, © M Nagai, N Fujita, IS Diouf, M Salla 2017. A Licence to publish this material has been given to James Cook University, http://www.jcu.edu.au 1 ie permanent government staff versus contract staff. Financial incentive schemes were less commonly suggested. Family bonding and religious-related non-financial incentive schemes were found to be specific factors in Senegal, but would also be applicable in countries where family and religion play important roles in the values of healthcare workers. Conclusions: Improved HRH management, eg the transparency of human resource management by the MoH, was identified as a pre-condition of any policy implementation related to HRH. This factor can be considered in other countries struggling to retain healthcare workers in rural areas. The Vision Tokyo 2010 Network or HRH managers’ network in Francophone Africa, Senegal MoH and the research team plan to conduct a quantitative survey to confirm the generalizability of the results of this qualitative survey, and to identify the most effective combination of policies to improve the retention of qualified healthcare workers and seek their implementation in other countries in the region as network activities. Key words: deployment, Francophone Africa, healthcare workers, human resource management, retention. Introduction their retention in rural areas as overarching problems in the member countries 11 . This study was planned, conducted and analyzed under the strong leadership of the network. Senegal Deployment and retention of a sufficient number of skilled and was chosen as the study area because it is one of the most motivated human resources for health (HRH) at the right place politically stable countries in the network. and at the right time are critical to ensure people’s right to access a universal quality of health care. However, an insufficient number The first objective of this study was to identify the and categories of HRH and their maldistribution have been determining factors for the retention of qualified HRH in common problems among countries off track of the Millennium rural areas by listening to healthcare personnel currently Development Goals. These phenomena are particularly prominent working in rural areas or those who left rural areas to work in in lower income countries where there is disparity between urban urban areas. The second objective was to explore the and rural areas in terms of socioeconomic status, including effective and feasible retention policies for the MoH to 1 infrastructures . This impedes the universal health coverage that is implement based on those identified determining factors. critically important to achieve Sustainable Development Goals, 2 especially goal 3 health targets . A comprehensive approach is Senegal is located in Sub-Saharan West Africa, which became necessary from the perspectives of production, recruitment, independent from France in 1960 (Fig1). The demographics of deployment and retention through regulation, as well as Senegal are shown in Table 1. The official language is French, but information and financial approaches by intersectoral stakeholders Wolof is also widely spoken. Approximately 96.1% of the 3 to achieve more equitable distribution of HRH . population practices Islam. Polygamy is known to be more common in rural areas 12 . There is at least one health center for Many countries have attempted to address the disparities in each health district that supervises health posts. Each health post is HRH, and there are many academic papers describing what located in communes or a rural community and headed by a nurse has worked 4. There is, however, a dearth of information from or midwife. Access to health services in rural areas is a challenge Francophone African countries that has been published in due to long distances via unpaved road from households to health English 5-7. In 2012, the innovative activities started in nine facilities or from health posts to health centers, with limited means Francophone African countries as Vision Tokyo 2010 of transport 13 . The concentration of HRH in the capital city of Network 8-10 , an international network of HRH managers at Dakar is striking, with 60% of medical doctors, 41% of nurses and the Ministry of Health (MoH) level (Box 1). The network 45% of midwives living in Dakar, while 80% of the population identified maldistribution of a limited number of healthcare live in places other than Dakar 14 . Table 2 shows the distribution of personnel such as medical doctors, nurses and midwives and healthcare personnel in Dakar and eight rural regions. There was © M Nagai, N Fujita, IS Diouf, M Salla 2017. A Licence to publish this material has been given to James Cook University, http://www.jcu.edu.au 2 no codified HRH law or policy to address the rural–urban identified based on the information from the regional health imbalance in Senegal when this study was conducted. The main department located in rural health districts. Convenience issues of HRH in Senegal have been the transformation from sampling was applied to selected group 3 interviewees. quantity to quality, the absorption capacity in public health facilities, and maldistribution. The dual practice of civil servants, For policy makers in the MoH, in-depth interviews were including healthcare personnel, is prohibited in Senegal. There are conducted, asking about their definition of a rural area, their 4 private hospitals, 24 private clinics, 414 private medical offices perceptions of the management of HRH, and their suggested and 700 private pharmacies in the whole country 14 . Most of them policies for deployment and retention of healthcare workers are located in urban areas. Those located in rural areas are mostly in rural areas. run by non-profit organizations. Data collection Methods The questionnaire and interview guide were developed in French. Four teams, composed of two interviewers and one Sample supervisor, who are all native Senegalese fluent both in French and Wolof, conducted the interviews with the three The participants in this study constituted three groups of groups of healthcare workers. Each interview was conducted healthcare workers and policy makers in the MoH: (1) those and recorded in Wolof when the interviewee preferred. The currently working in a rural area for more than two years, (2) first author and the supervisor conducted the in-depth those currently working in Dakar with experience of working interviews with policy makers in French. in a rural area and (3) those currently working in Dakar without any prior experience working in a rural area. Interviews were conducted between January and March 2014 in a private room in the health facilities where the interviewee Open-ended questionnaires were administered to the worked. To maintain confidentiality, only the interview team and participants in the three groups, asking about their the interviewee were in the room during the interview. Each willingness and reasons for accepting to work or continue interview took 30–90 minutes. All interviews were recorded working in a rural area, and their suggested policies for using both audio and video recorders. deployment and retention of healthcare workers in rural areas. Participants included medical doctors, nurses, Data analysis midwives, and superior technicians in anesthesiology (STA).