Using the socio-ecological model to appraise perspectives on health workforce retention and intention to leave in Malawi and Tanzania: a qualitative longitudinal study

Introduction: The chronic health workforce shortage poses a significant setback to achieving Universal Health Coverage. Health authorities continually develop and implement human resources for health policies and interventions to alleviate the crisis, including retention policies. However, the success of such policies and interventions is tangent to the alignment with health workers’ expectations.
Aim: To explore perspectives on health workforce retention and intention to leave among health workers and policy makers from rural and remote areas of Malawi and Tanzania.
Methods: We conducted semi-structured interviews with 120 participants, 111 rural and remote mid-level health workers, and nine policymakers in Malawi and Tanzania for a period of three years, 2014 to 2017. We conducted the semi-structured interviews face-to-face, and follow-up interviews through emails, or social media. Using the Socio-Ecological Model as a framework for analysis, we mapped out and linked the emerging themes.
Results: Health workers related their perspectives on retention and intention to leave to the individual (intrapersonal), family (interpersonal/microsystem), and community (institutional/mesosystem) factors, whereas the policymakers focused their views mainly on the individual (intrapersonal), factors, and the retention policies at the national level (macrosystem).
Conclusions: Policymakers and health workers in rural and remote settings in Malawi and Tanzania recognise the factors influencing health workforce retention, and intention to leave at the individual level. However, while policymakers’ focus mainly on national-level retention policies, health workers focus on retention aspects related to the family and the surrounding community – a clear misalignment. Therefore, health authorities need to align health policies to health workers’ expectations to bridge this gap, improve access to the health workforce in rural and remote populations and improve health outcomes.