SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
January, 2017 - SUPPORT Summary of a systematic review | print this article | download PDF
Shortages of health professionals in many geographic regions, especially in underserved and rural areas, challenge equitable healthcare delivery and pose an important obstacle to the achievement of health goals.
Key messages
-Educational interventions (e.g. student selection criteria, undergraduate and postgraduate teaching curricula, exposure to rural and urban underserved areas)
-Financial interventions (e.g. undergraduate and postgraduate bursaries or scholarships linked to future practice location, rural allowances, increased public sector salaries)
-Regulatory strategies (e.g. compulsory community service, relaxing work regulations imposed on foreign medical graduates who are willing to work in rural or urban underserved areas)
-Personal and professional support strategies (e.g. providing adequate professional support and attending to the needs of the practitioners family)
Grobler L, Marais BJ, Mabunda S. Interventions for increasing the proportion of health professionals practising in rural and other underserved areas. Cochrane Database of Systematic Reviews 2015, Issue 6. Art. No.: CD005314.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
There is an imbalance in the distribution of health professionals between underserved and well-served areas in most parts of the world. Most health professionals practice in urban rather than rural areas. Fewer healthcare professionals work in underserved rural and urban communities. The reasons for this include: more demanding working conditions, substandard medical equipment and facilities, inadequate financial remuneration, inadequate opportunities for personal and professional growth, safety concerns, a lack of job opportunities for spouses, and the limited educational opportunities available to children. Addressing the maldistribution of health professionals is critical in order to ensure greater equity and the achievement of health goals.
This summary addresses the effects of different interventions to increase the number of health professionals practising in rural and other underserved areas in low-income countries. It summarises a broad review of interventions designed to increase the proportion of health professionals practising in underserved communities.
| Review objectives: To assess the effectiveness of interventions to increase the proportion of healthcare professionals working in rural and other underserved areas | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions | Randomized trials, non-randomized trials, controlled before-after studies and interrupted time series studies of any intervention to increase the recruitment or retention of health professionals in underserved areas. |
1 interrupted time series study from Taiwan of the effects of National Health Insurance on the equality of distribution of healthcare professionals |
| Participants | Qualified healthcare professionals of any cadre or specialty |
Physicians, doctors of Chinese medicine and dentists |
| Settings | All settings |
Taiwan |
| Outcomes | Recruitment of health professionals: the proportion of health professionals who initially choose to work in rural or urban underserved communities as a result of being exposed to the intervention. Retention: the proportion of healthcare professionals who continue to work in rural or urban underserved communities as a consequence of the intervention |
Equality of geographic distribution of healthcare professionals measured using the Gini coefficient |
| Date of most recent search: April 2014 | ||
| Limitations: This is a well-conducted systematic review with only minor limitations. | ||
Grobler L, Marais BJ, Mabunda S. Interventions for increasing the proportion of health professionals practising in rural and other underserved areas. Cochrane Database of Systematic Reviews 2015, Issue 6. Art. No.: CD005314.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
The review identified one study conducted in Taiwan. This study assessed the impacts of the introduction of a mandatory national health insurance scheme, using time series observations over 32 years. The scheme had multiple components including a single-payer system and comprehensive benefits for allopathic and Chinese medicine and dental care.
-Educational interventions (e.g. student selection criteria, undergraduate and postgraduate teaching curricula, exposure to rural and urban underserved areas)
-Financial interventions (e.g. undergraduate and postgraduate bursaries or scholarships linked to future practice location, rural allowances, increased public sector salaries)
-Regulatory strategies (e.g. compulsory community service, relaxing work regulations imposed on foreign medical graduates who are willing to work in rural or urban underserved areas)
-Personal and professional support strategies (e.g. providing adequate professional support and attending to the needs of the practitioners family)
|
Introduction of a mandatory national health insurance scheme, including a single-payer system and comprehensive benefits for allopathic and Chinese medicine and dental care |
||||
| People: Healthcare professionals Settings: Taiwan Intervention: Mandatory national health insurance scheme Comparison: No national health insurance scheme |
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| Outcomes | Impact | Number of participants (Studies) |
Certainty of the evidence (GRADE) |
|
| Equality of distribution of healthcare professionals |
The equality of geographic distribution increased as follows:
|
(1 study) |
Very Low |
|
| p: p-value, SE – standard error GRADE: GRADE Working Group grades of evidence (See above and last page) | ||||
|
Findings |
Interpretation* |
|---|---|
|
APPLICABILITY |
|
|
Some observational studies, mostly from high-income countries, suggest that some interventions, such as selecting students from rural areas, exposing students to clinical rotations in rural areas, or financial incentive programmes might increase the number of health professionals in underserved areas. However, the certainty of this evidence is very low. |
Economic and cultural differences, differences between health system structures, and differences in state and educational institutional capacity to regulate and manage various types of interventions may limit the applicability of findings from high to low-income countries. |
|
EQUITY |
|
|
The one included study suggested that a mandatory national insurance scheme might slightly reduce the inequitable distribution of health professionals, possibly by removing financial disincentives. |
Any intervention that increases the proportion of health professionals in underserved areas would improve equitable access to healthcare. |
|
ECONOMIC CONSIDERATIONS |
|
|
Only one study was included and it did not provide evidence cost or cost-effectiveness. |
The cost and cost-effectiveness of different interventions for recruiting or retaining health professionals in underserved areas is uncertain. |
|
MONITORING & EVALUATION |
|
|
Although many different interventions are used to recruit and retain health professionals in underserved areas, the effectiveness of these interventions is uncertain. |
The effects, including possible adverse effects, and costs of any intervention that is implemented to recruit or retain health professionals in underserved areas should be monitoried and, if possible, the impact on the number of health professionals practicing in underserved areas should be evaluated using randomized trials or interupted time series studies. |
| *Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods | |
Related literature
World Health Organization. Increasing access to health workers in remote and rural areas through improved retention: Global policy recommendations. Geneva: World Health Organization, 2010. http://www.who.int/hrh/retention/guidelines/en/index.html
Wilson NW, Couper ID, De Vries E, Reid S, Fish T, Marais BJ. A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas. Rural and Remote Health 9: 1060. (Online), 2009.
Bärnighausen T, Bloom DE. Financial incentives for return of service in underserved areas: a systematic review. BMC Health Services Research 2009; 9:86.
Bärnighausen T, Bloom DE (2009). Designing financial-incentive programs for return of service in underserved areas: seven management functions. Human Resources for Health, 7(1): 52.
Lehmann U, Dieleman M, Martineau T. Staffing remote rural areas in middle- and low-income countries: A literature review of attraction and retention. BMC Health Services Research 2008, 8:19.
Willis-Shattuck M, Bidwell P, Thomas S, Wyness L, Blaauw D and Ditlopo P. Motivation and retention of health workers in developing countries: a systematic review. BMC Health Services Research 2008, 8:247.
This summary was prepared by
Charles I. Okwundu, Faculty of Health Sciences Stellenbosch University, South Africa
Conflict of interest
None declared. For details, see: www.supportsummaries.org/coi
Acknowledgements
This summary has been peer reviewed by:Liesl Nicol, Till Bärnighausen, and Elie Akl
This review should be cited as
Grobler L, Marais BJ, Mabunda S. Interventions for increasing the proportion of health professionals practising in rural and other underserved areas. Cochrane Database of Systematic Reviews 2015, Issue 6. Art. No.: CD005314.
The summary should be cited as
Okwundu CI, Lewin S. Which interventions increase the recruitment and retention of health professionals practising in underserved and rural areas? A SUPPORT summary of systematic reviews. August 2016. www.supportsummaries.org
Keywords
All Summaries:
Evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care, recruitment, retention, health professionals, health workers, underserved areas, rural areas, remote areas.
