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 Dentists Fatick – 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% 80% – Regions with lower health 70% 60% professionals density tend to have a 50% lower coverage of births by skilled 40% attendants (%) 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 lower coverage of births by skilled doctors, nurses and midwives per 1000 population 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 meeting consultations, drafting - 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.