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

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 policy. 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.

Available from: http://www.rrh.org.au 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 policy 1 .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 onepage 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 wellsupported 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 .
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 factors 4 .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 Assembly 5 .
In summary, this report provides a systematic analysis of the research on the education, recruitment and retention of rural health workers with carefully constructed, evidenceinformed 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 Guidelines 6 .
A. EDUCATION RECOMMENDATIONS 1. Use targeted admission policies to enrol students with a rural background in education programmes for various health disciplines, in order to increase the likelihood of graduates choosing to practise in rural areas.2. Locate health professional schools, campuses and family medicine residency programmes outside of capitals and other major cities as graduates of these schools and programmes are more likely to work in rural areas.

Expose undergraduate students of various health disciplines to rural community experiences and clinical rotations as these can
have a positive influence on attracting and recruiting health workers to rural areas.4. Revise undergraduate and postgraduate curricula to include rural health topics so as to enhance the competencies of health professionals working in rural areas, and thereby increase their job satisfaction and retention.5. Design continuing education and professional development programmes that meet the needs of rural health workers and that are accessible from where they live and work, so as to support their retention.

B. REGULATORY RECOMMENDATIONS
1. Introduce and regulate enhanced scopes of practice in rural and remote areas to increase the potential for job satisfaction, thereby assisting recruitment and retention.2. Introduce different types of health workers with appropriate training and regulation for rural practice in order to increase the number of health workers practising in rural and remote areas.3. Ensure compulsory service requirements in rural and remote areas are accompanied with appropriate support and incentives so as to increase recruitment and subsequent retention of health professionals in these areas.4. Provide scholarships, bursaries or other education subsidies with enforceable agreements of return of service in rural or remote areas to increase recruitment of health workers in these areas.

C. FINANCIAL INCENTIVES RECOMMENDATION
1. Use a combination of fiscally sustainable financial incentives, such as hardship allowances, grants for housing, free transportation, paid vacations, etc., sufficient enough to outweigh the opportunity costs associated with working in rural areas, as perceived by health workers, to improve rural retention.

D. PERSONAL AND PROFESSIONAL SUPPORT RECOMMENDATIONS
1. Improve living conditions for health workers and their families and invest in infrastructure and services (sanitation, electricity, telecommunications, schools, etc.), as these factors have a significant influence on a health worker's decision to locate to and remain in rural areas.2. Provide a good and safe working environment, including appropriate equipment and supplies, supportive supervision and mentoring, in order to make these posts professionally attractive and thereby increase the recruitment and retention of health workers in remote and rural areas.3. Identify and implement appropriate outreach activities to facilitate cooperation between health workers from better served areas and those in underserved areas, and, where feasible, use telehealth to provide additional support to health workers in remote and rural areas.4. Develop and support career development programmes and provide senior posts in rural areas so that health workers can move up the career path as a result of experience, education and training, without necessarily leaving rural areas.5. Support the development of professional networks, rural health professional associations, rural health journals, etc., in order to improve the morale and status of rural providers and reduce feelings of professional isolation.6. Adopt public recognition measures such as rural health days, awards and titles at local, national and international levels to lift the profile of working in rural areas as these create the conditions to improve intrinsic motivation and thereby contribute to the retention of rural health workers.

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