To increase access to health care, we need more health workers. And we need them to be where the people are—not just in cities but in remote areas too. Of course, attracting health workers to rural service isn’t easy, nor is keeping them there.

About half of all people on the planet live in rural areas. But health workers are concentrated in cities. According to the World Health Organization, only about 25% of physicians and 38% of nurses work in rural areas.

So how can we increase access to health workers in remote areas? Dr. Carmen Dolea, technical officer at of the World Health Organization and a leading expert in health workforce migration and retention, has been thinking about this challenge for a while.

A need for action

“I am a physician,” says Dr. Dolea, “and I work at WHO in the area of human resources for health.” Back in 2008, she noted a growing focus on health worker retention. “There was beginning to be strong interest from international bodies,” Dr. Dolea recalls, “and there was a specific request from the resolutions of WHO on rapid scaling up of health workers to pay careful attention to the issues of rural/urban imbalances.” Following the First Global Forum on Human Resources for Health, “there was also a request from the Kampala Declaration and the Agenda for Global Action to come up with recommendations of how to improve the retention of health workers in rural areas.”

Clearly there was a need to help countries take action. “Member states need to come up with effective options to solve the problem,” she says. “There’s no onesize-fits-all solution that will solve the problem, but an appropriate combination for the country itself is what is needed.”
 

New evidence-based recommendations

Recently the WHO issued global policy recommendations for increasing access to health workers through improved retention in remote and rural areas. “We approached this from an evidence-based perspective,” Dr. Dolea points out, “and we embarked on this issue with expert consultations.”

Dr. Dolea emphasizes that countries should consider the recommendations “within the overall development of the national human resources for health plan.” Following analysis of the current situation and needs, policy-makers can “come up with a priority list of interventions that are most appropriate for the country context and situation.”

As Dr. Dolea notes, countries should develop tailored bundles of interventions to attract health workers to rural service and encourage them to stay.

CapacityPlus’s role

CapacityPlus, the IntraHealth International-led global project that focuses on the health workforce needed to achieve the Millennium Development Goals, is partnering with the WHO to help apply the retention recommendations in country-specific settings. In Uganda, for example, CapacityPlus has helped the Ministry of Health obtain health worker preferences to assist in designing bundles of incentives and other retention interventions.

“CapacityPlus has been involved from the beginning,” Dr. Dolea remarks. “We worked together with colleagues from CapacityPlus to fill the evidence gaps, draft the guidelines, and to eventually finalize them. We continue this collaboration, and we would like to develop together with CapacityPlus and the World Bank a road map for supporting countries to select, implement, and evaluate the most appropriate strategies.”

Assessing the impact

Looking ahead, Dr. Dolea says, the WHO and partners will be “documenting what’s happening in different countries that have taken up the recommendations or that have started to implement retention strategies.” Three years from now, “we will see whether anything has improved and how it has improved.”

We need to find ways to keep dedicated health workers in the communities that urgently need their services. Health workers’ motivations are complex, and salary is only one part of the picture. Using the WHO recommendations, we can help countries move closer to staffing their remote health posts with professionals who want to be there—and increase access to care.

Special thanks to Carmen Dolea, and to Laura Wurts for interviewing Dr. Dolea in Indonesia.

A version of this piece was originally published as Voices#2, on the CapacityPlus website.