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
April, 2011 - SUPPORT Summary of a systematic review | print this article |
Shortages of health workers in many geographic regions (especially in under-served and rural areas) challenge equitable healthcare delivery and pose an important obstacle to the achievement of the Millenium Development Goals.
People making decisions concerning the recruitment and retention of health workers practising under-served areas.
Grobler LA, Marais BJ, Mabunda S, Marindi P, Reuter H, Volmink J. Interventions for increasing the proportion of health professionals practising in under-served communities. Cochrane Database of Systematic Reviews 2009, Issue 1.
See in Cochrane Library
Till Bärnighausen and David E Bloom. Financial incentives for return of service in underserved areas: A systematic review. BMC Health Services Research 2009, 9:86. See in Publisher Site
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 workers between under-served and well-served areas in most parts of the world, with most practising in urban rather than rural areas. Fewer healthcare professionals work in under-served rural and urban communities. The reasons for this include: the more demanding working conditions, the use of 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 workers is critical in order to ensure that greater equity (health for all) is achieved and that the Millenium Development Goals are fulfilled/met.
This summary addresses the effects of different interventions to in-crease the number of health workers practising in rural and other under-served areas in low- and middle-income countries. It summarises a broad review of interventions designed to increase the proportion of health professionals practising in under-served communities. It also summarises a more focused review of the financial incentives used to promote the return of health workers to under-served areas.
| Review Objectives: To assess the effectiveness of interventions to increase the proportion of healthcare professionals working in rural and other under-served communities | ||
| / | What the review authors searched for | What the review authors found |
|---|---|---|
| Interventions | Any intervention to increase the recruit-ment or retention of health workers in un-der-served areas. RCTs, controlled trials, controlled before-and-after studies and interrupted time series were included | No studies met the inclusion criteria of the review |
| Participants |
All qualified healthcare professionals of any cadre or specialty |
|
| Settings | Not specified |
|
| Outcomes |
Recruitment of health workers: the proportion of health workers who initially choose to work in rural or urban under-served 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 |
Most studies were descriptive questionnaire-driven surveys, and few were prospective intervention studies. Most studies reported multiple effect measures and many did not specify a primary outcome |
| Date of most recent search: July 2007 | ||
| Limitations: This is a good quality systematic review with only minor limitations | ||
| Review Objectives: To assess the effectiveness of financial incentives for the return of health workers to under-served areas. | ||
| / | What the review authors searched for | What the review authors found |
|---|---|---|
| Interventions | Any study evaluating the effects of financial incentives for the return of health workers to under-served areas |
43 observational studies met the inclusion criteria of the review |
| Participants |
All qualified healthcare professionals of any cadre or specialty |
|
| Settings | High- and middle-income countries |
43 studies conducted in the United States of America (USA) (34), Japan (5), Canada (2),New Zealand (1) and South Africa (1) |
| Outcomes |
Recruitment of health workers |
Results: Recruitment (14 studies), retention (17 studies), participants satisfaction (9 studies) |
| Date of most recent search: February 2009 | ||
| Limitations: This is a good quality systematic review with only minor limitations | ||
Grobler LA, Marais BJ, Mabunda S, Marindi P, Reuter H, Volmink J. Interventions for increasing the proportion of health professionals practising in under-served communities. Cochrane Database of Systematic Reviews 2009, Issue 1.
See in Cochrane Library
Till Bärnighausen and David E Bloom. Financial incentives for return of service in underserved areas: A systematic review. BMC Health Services Research 2009, 9:86. See in Publisher Site
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.
No studies met the inclusion criteria of the review. 90 studies were identified that did not meet the study design criteria of the review but were relevant to the review question. The main findings from these are summarised in the table below. This table, with minor modifications, is from the original report and is used with the permission of the review authors.
| Intervention |
Main findings |
Comments |
|
STUDENT SELECTION |
||
| Geographic origin |
Students of rural origin are more likely to practise in a rural setting |
This single factor most strongly associated with rural practice. Background of spouse seems equally important |
| Ethnicity |
Students from ‘under-served’ populations are more likely to practise in these same communities |
Documented in only one study that evaluated mostly under-served inner-city populations, no association with rural practice per se |
| Gender | Students whose intent at study entry is to practise rural medicine are more likely to do so | May change if more accommodating conditions are created for women. Important to have female rural doctors in culturally sensitive settings |
| Career intent | Students whose intent at study entry is to practise rural medicine are more likely to do so | Independent predictor of rural practice in the PSAP*, but 60% of rural doctors in the USA reported no such career intent initially |
| Service orientation | Students who report involvement in volunteer activities are more likely to practise rural medicine | Observation at the University of North Carolina (USA) that such students are more likely to become generalists, but no evidence of [a commitment to?] rural practice |
| Undergraduate | ||
| Curriculum content | Emphasising the importance of rural health issues may influence medical students to consider practising in rural areas |
No evidence that the content of the undergraduate curriculum influences the decision to enter rural practice |
| Rural exposure | Clinical rotations in a rural setting may influence medical students to consider rural practice | Actual clinical exposure (immersion) seems most important, although the perceived impact of rural rotations may be biased by self-selection |
| Postgraduate | ||
| Generalist fellowships | The availability of generalist fellowships encourages more doctors to enter into rural practice | Rural health specialists and family physicians are more likely to enter rural practice, but there is no evidence that the creation/availability of these specialities actually reduces the rural-urban maldistribution |
|
Undergraduate students from medical schools that offer generalist fellowships are more likely to become rural doctors |
Many potential confounders, impossible to assess the strength of the evidence in the absence of multivariate analysis | |
| Location | Students from medical schools located in rural areas are more likely to practise in a rural setting | Rural placement may be a surrogate of various other factors. However, there is fairly strong evidence that rural medical schools do produce more rural doctors |
|
Registration requirement
|
Requiring recently qualified doctors to perform ‘community service’ in a rural area reduces maldistribution |
Forced ‘community service’ addresses short-term recruitment, but there is concern that it may alienate people from the profession and from long-term rural practice |
|
Pre-requisite for specialisation |
Requiring doctors to spend a minimum number of years in a rural area in order to specialise reduces maldistribution |
Applied in many developing countries, but criticised in Indonesia for attracting the ‘wrong type’ of doctor to rural areas and for reducing the return on investment placed in specialised training |
|
International recruitment |
Recruiting foreign doctors, and limiting them to rural practice reduces maldistribution | Foreign recruitment is widely practised. It offers a short-term solution for those countries importing doctors. However, it often results in a shortage of health professionals in the exporting country which may worsen global distribution imbalances. |
| FINANCIAL INCENTIVES | ||
| Bursaries/scholarships | Providing scholarships with enforceable rural service agreements encourages rural practice | Variable experience in different countries. The WHO concluded in a report that these policies have little influence on the geographic distribution of health professionals |
| Financial compensation | Providing direct financial incentives encourages rural practice | In Canada, allowing higher fees in rural areas had a positive influence on general practitioner distribution. Reports from most developing countries are not positive |
| SUPPORT | ||
| Continuous Professional development | Providing sufficient opportunities for professional support encourages rural practice |
Only questionnaire-based surveys |
| Specialist outreach support | Providing specialist outreach and support encourages rural practice | |
| Personal issues | Providing sufficient personal support encourages rural practice |
Only questionnaire-based surveys |
| Time-off | Providing back-up to allow free time during holidays and weekends encourages rural practice |
43 observational studies investigated financial incentive programmes for return to service in under-served areas. The studies were conducted in the USA (34), Japan (5), Canada (2), New Zealand (1) and South Africa (1).
However, these findings are mostly from high-income countries and are not consistent with the findings of the first systematic review summarised in this study. Reports from most low- and middle-income countries are not positive.
Financial incentives |
|||
| Patient or population: Health workers Settings: High- and middle-income countries Intervention: Financial incentives Comparison: Not specified |
|||
| Outcomes | Impact |
Number of participants |
Quality of the evidence |
| Recruitment |
Recruitment proportion varied between 33% and 100% across programme participants who remained in under-served areas |
(14 studies) |
|
| Retention |
The proportion of programme participants who remained in under-served areas after completing their obligation ranged between 12% and 90% |
(24 studies) |
|
| Participant satisfaction | There were too few studies so strong generalised inferences could not be drawn | (9 studies) |
|
| Family satisfaction | There were too few studies so strong generalised inferences could not be drawn | (3 studies) |
|
| GRADE: GRADE Working Group grades of evidence (see above and last page) | |||
| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
|
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| EQUITY | |
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| ECONOMIC CONSIDERATIONS | |
|
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| MONITORING & EVALUATION | |
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*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- and middle-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm |
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Related literature
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.
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.
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
Bärnighausen T, Bloom DE (2009). Designing financial-incentive programs for return of service in under-served areas: seven management functions. Human Resources for Health, 7(1): 52.
This summary was prepared by
Charles I. Okwundu, Faculty of Health Sciences Stellenbosch University, South Africa
Conflict of interest
None. For details, see: Conflicts of Interest
Acknowledgements
This summary has been peer reviewed by: Liesl Nicol, South Africa; Till Bärnighausen, USA; Elie Akl, USA
This summary should be cited as
Okwundu CI. Which interventions increase the recruitment and retention of health workers practising in under-served and rural areas? A SUPPORT Summary of a systematic review. April 2011.
