Financial incentives for return of service in underserved areas: a systematic review

Background  

In many geographic regions, both in developing and in developed countries, the number of health workers is insufficient to achieve population health goals. Financial incentives for return of service are intended to alleviate health worker shortages: A (future) health worker enters into a contract to work for a number of years in an underserved area in exchange for a financial pay-off.     

Indian approaches to retaining skilled health workers in rural areas

Problem

The lack of skilled service providers in rural areas of India has emerged as the most important constraint in achieving universal health care. India has about 1.4 million medical practitioners, 74% of whom live in urban areas where they serve only 28% of the population, while the rural population remains largely underserved.

Approach

The National Rural Health Mission, launched by the Government of India in 2005, promoted various state and national initiatives to address this issue. Under India’s federal constitution, the states are responsible for implementing the health system with financial support from the national government.

Local setting

The availability of doctors and nurses is limited by a lack of training colleges in states with the greatest need as well as the reluctance of professionals from urban areas to work in rural areas. Before 2005, the most common strategy was compulsory rural service bonds and mandatory rural service for preferential admission into post-graduate programmes.

Relevant changes

Initiatives under the National Rural Health Mission include an increase in sanctioned posts for public health facilities, incentives, workforce management policies, locality-specific recruitment and the creation of a new service cadre specifically for public sector employment. As a result, the National Rural Health Mission has added more than 82 343 skilled health workers to the public health workforce.

Lessons learnt

The problem of uneven distribution of skilled health workers can be solved. Educational strategies and community health worker programmes have shown promising results. Most of these strategies are too recent for outcome evaluation, although this would help optimize and develop an ideal mix of strategies for different contexts.     

Which incentive package will retain regionalized health personnel in Burkina Faso: a discrete choice experiment

Background

The lack of motivation of health workers to practice in rural areas remains a crucial problem for decision-makers, as it deprives the majority of access to health care. To solve the problem, many countries have implemented health worker retention strategies. However, the development of such strategies requires an understanding of the preferences of health workers. The objective of the study was to identify a package for attracting and retaining health workers in underserved areas.

Methods

A cross sectional study was conducted in three health regions of Burkina Faso in 2012. A discrete choice experiment was used to investigate preferences for incentive packages among health workers recruited under the regionalized policy. In-depth interviews and focus group discussions with health workers currently working in the East and Sahel regions and policy makers, and a literature review on attraction and retention in low income countries, were performed to identify the attributes and levels. These attributes were: the regionalized recruitment policy, health insurance, work equipment, housing, and specific incentive compensation. The final design resulted in 16 choice sets. A multinomial logistic regression was used to determine the influence of socio-demographic characteristics on choice of a given option. A probit logistic regression model was then used to analyze the effect of these difference variables on choice, to identify the incentive package best suited to health workers. In total, questionnaires were administered to 315 regional health workers.

Results

For all participants, choice of package was strongly influenced by length of commitment under the policy and provision of housing. Sex, number of years in profession, and location also influenced the choice of package. Women are twice more likely to choose a package with free housing and the cancellation of the policy.

Conclusion

It is important that governments consider health worker preferences in crafting policies to address attraction and retention in underserved areas. In addition, the methodology of discrete choice experiment has been particularly useful, not only for better understanding the factors explaining the reluctance of health workers to work in underserved areas, but also to provide practical advice to the government, to improve its retention policy.

     

Context counts: training health workers in and for rural and remote areas

Access to well trained and motivated health workers is the major rural health issue. Without local access, it is unlikely that people in rural and remote communities will be able to achieve the Millennium Development Goals. Studies in many countries have shown that the three factors most strongly associated with entering rural practice are: (i) a rural background; (ii) positive clinical and educational experiences in rural settings as part of undergraduate medical education; and (iii) targeted training for rural practice at the postgraduate level. This paper presents evidence for policy initiatives involving the training of medical students from, in and for rural and remote areas. We give examples of medical schools in different regions of the world that are using an evidence-based and context-driven educational approach to producing skilled and motivated health workers. We demonstrate how context influences the design and implementation of different rural education programmes. Successful programmes have overcome major obstacles including negative assumptions and attitudes, and limitations of human, physical, educational and financial resources. Training rural health workers in the rural setting is likely to result in greatly improved recruitment and retention of skilled health-care providers in rural underserved areas with consequent improvement in access to health care for the local communities.     

Lay health worker attrition: important but often ignored

Lay health workers are key to achieving universal health-care coverage, therefore measuring worker attrition and identifying its determinants should be an integral part of any lay health worker programme. Both published and unpublished research on lay health workers has largely focused on the types of interventions they can deliver effectively. This is an imperative since the main objective of these programmes is to improve health outcomes. However, high attrition rates can undermine the effectiveness of these programmes. There is a lack of research on lay health worker attrition. Research that aims to answer the following three key questions would help address this knowledge gap: what is the magnitude of attrition in programmes? What are the determinants of attrition? What are the most successful ways of reducing attrition? With community-based interventions and task shifting high on the United Nations Millennium Development Goals’ policy agenda, research on lay health worker attrition and its determinants requires urgent attention.     

Motivation and retention of health workers in developing countries: a systematic review

Background  

A key constraint to achieving the MDGs is the absence of a properly trained and motivated workforce. Loss of clinical staff from low and middle-income countries is crippling already fragile health care systems. Health worker retention is critical for health system performance and a key problem is how best to motivate and retain health workers. The authors undertook a systematic review to consolidate existing evidence on the impact of financial and non-financial incentives on motivation and retention.     

Burnout and use of HIV services among health care workers in Lusaka District, Zambia: a cross-sectional study

Background  

Well-documented shortages of health care workers in sub-Saharan Africa are exacerbated by the increased human resource demands of rapidly expanding HIV care and treatment programmes. The successful continuation of existing programmes is threatened by health care worker burnout and HIV-related illness.     

Effective scale-up: avoiding the same old traps

Despite progress in developing more effective training methodologies, training initiatives for health workers continue to experience common pitfalls that have beset the overall success and cost-effectiveness of these programs for decades. These include lack of country-level coordination of health training, inequitable access to training, interrupted services, and failure to reinforce skills and knowledge training by addressing other performance factors. These pitfalls are now seen as aggravating the current crisis in human resources for health and impeding the effective scale-up of training and the potential impact of promising strategies such as task shifting to address health worker shortages. Drawing on IntraHealth International's lessons learned in designing reproductive health and HIV/AIDS training and performance improvement programmes, this commentary discusses promising practices for strengthening human resources for health through more efficient and effective training and learning programmes that avoid the same old traps. These promising practices include the following:     

The female community health volunteer programme in Nepal: Decision makers’ perceptions of volunteerism,payment and other incentives

The Female Community Health Volunteer (FCHV) Programme in Nepal has existed since the late 1980s and includes almost 50,000 volunteers. Although volunteer programmes are widely thought to be characterised by high attrition levels, the FCHV Programme loses fewer than 5% of its volunteers annually. The degree to which decision makers understand community health worker motivations and match these with appropriate incentives is likely to influence programme sustainability. The purpose of this study was to explore the views of stakeholders who have participated in the design and implementation of the Female Community Health Volunteer regarding Volunteer motivation and appropriate incentives, and to compare these views with the views and expectations of Volunteers. Semi-structured interviews were carried out in 2009 with 19 purposively selected non-Volunteer stakeholders, including policy makers and programme managers. Results were compared with data from previous studies of Female Community Health Volunteers and from interviews with four Volunteers and two Volunteer activists. Stakeholders saw Volunteers as motivated primarily by social respect, religious and moral duty. The freedom to deliver services at their leisure was seen as central to the volunteer concept. While stakeholders also saw the need for extrinsic incentives such as micro-credit, regular wages were regarded not only as financially unfeasible, but as a potential threat to the Volunteers’ social respect, and thereby to their motivation. These views were reflected in interviews with and previous studies of Female Community Health Volunteers, and appear to be influenced by a tradition of volunteering as moral behaviour, a lack of respect for paid government workers, and the Programme’s community embeddedness. Our study suggests that it may not be useful to promote a generic range of incentives, such as wages, to improve community health worker programme sustainability. Instead, programmes should ensure that the context-specific expectations of community health workers, programme managers, and policy makers are in alignment if low attrition and high performance are to be achieved.     

Migration of allied health care personnel in and out of an underserved area: a question of roots

The distribution of health personnel and the resulting shortages of health care to economically depressed, ethnic, rural and inner city areas is a serious problem. Recruiting students from and training them in underserved areas has been suggested as one way to improve retention rates among graduates of allied health programs. A one-year follow-up survey of 1974 graduates of allied health programs sponsored by an Area Health Education Center located in an underserved, one ethnic group predominant rural area was done to test this approach. Results show that of the 122 graduates surveyed in this study, one year after graduation 85% had returned to work in the area of their previous residence. Among professional groups, licensed vocational nurses experienced the least migration. Generally, professions requiring higher levels of education showed higher relocation rates. Sex and ethnicity were related to these findings. The appeal of higher salaries or material benefits alone did not appear to attract graduates to migrate. It appears that communities with shortages of health manpower due to maldistribution may be successful in correcting this problem by recruiting students from their own area. Possible explanations and recommendations related to these findings are discussed.     

A comparison of the perceptions and beliefs of workers and owners with regard to workplace safety in small metal fabrication businesses

BACKGROUND: Problems of improving safety in small business establishments may include a lack of resources, limited unionization, and an informal management structure. METHODS: We evaluated worker and manager perceptions of worksite health and safety using Social Cognitive Theory. We used a business safety scorecard to audit the safety conditions, policies and programs, and work practices. Comparisons were made between the different measures. RESULTS: Businesses with safety committees had 1.7-2.1 times higher proportion of positive safety scorecard items than businesses without committees. Union status and business size were not associated with business safety audit results. Non-English-speaking and less educated employees reported higher levels of knowledge about safety than did their more educated and/or English-speaking peers. CONCLUSIONS: The presence of a safety committee is the single most important indicator of workplace safety. Self-reported understanding of workplace safety is greater among employees who do not speak English or have lower levels of formal education. Future worksite interventions should consider the need for participatory worksite safety committees. Multilingual training programs would help reach a greater proportion of workers.     

Attraction and retention of qualified health workers to rural areas in Nigeria: a case study of four LGAs in Ogun State, Nigeria

INTRTODUCTION: A shortage of health workers is a major problem for Nigeria, especially in rural areas where more than 70% of the population live. At the primary care level, trained community health officers provide services normally reserved for doctors or medical specialists. The community health officers must therefore be supported and motivated to provide effective quality healthcare services. This study aimed to determine factors that will attract and retain rural and urban health workers to rural Nigerian communities, and to examine differences between the two groups. METHODS: A cross-sectional survey measured health workers' work experience, satisfaction with, and reasons for undertaking their current work; as well as reasons for leaving a work location. Data were also gathered on factors that attract health workers to rural settings and also retain them. RESULTS; Rural health workers were generally more likely to work in rural settings (62.5%) than their urban counterparts (16.5%). Major rural motivators for both groups included: assurances of better working conditions; effective and efficient support systems; opportunities for career development; financial incentives; better living conditions and family support systems. The main de-motivator was poor job satisfaction resulting from inadequate infrastructure. Rural health workers were particularly dissatisfied with career advancement opportunities. More urban than rural health workers expressed a wish to leave their current job due to poor job satisfaction resulting from poor working and living conditions and the lack of career advancement opportunities. CONCLUSIONS: Motivational factors for attraction to and retention in rural employment were similar for both groups although there were subtle differences. Addressing rural health manpower shortages will require the development of a comprehensive, evidence-based rural health manpower improvement strategy that incorporates a coordinated intersectoral approach, involving partnership with a range of stakeholders in rural health development.     

西部地区卫生人力资源存在的问题及对策

目的我国西部贫困地区严重短缺"合格的职业卫生工作者",该研究旨在了解西部地区卫生人力资源现状及存在的问题,从激励机制上探讨卫生工作者面临的问题,并提出相关对策,为引进更多卫生人才到此类地区工作制定相关政策提供依据。方法采用问卷调查与定性访谈,对西部地区4个省(区)的县级医院、乡镇卫生院和村卫生室卫生人员进行调查,对相关卫生政策制定者进行深度访谈。结果卫生工作者学历以中专、大专居多,职称以初级职称为主,岗位以临床医生与护士居多且医生多于护士。西部地区县、乡镇及村卫生室普遍缺乏卫生工作者,培训机会少、待遇低等诸多因素造成该地区卫生人才流失。结论 (1)在需要引进卫生人才的偏远地区提高非编制聘用的工资待遇标准,增加卫生工作人员的培训机会。(2)重点解决村一级卫生机构的功能问题和可持续发展,继续加强职业道德和医学道德的宣传。(3)解决卫生人力政策与其他相关政策之间的矛盾,使其和谐共处发展。     

Memisa: from medical missionary action into a medical relief organization

In the past seventy years Memisa Medicus Mundi has grown into an organization accounting for about half the annual number of Dutch health care workers in third world countries. On top of this, it gives financial and material support to many development programmes in Africa, Asia and Latin America. Of all aid, 82% is given to so-called structural programmes and 18% to disaster relief. Physicians who return to the Dutch health care system as general practitioners after a period abroad are capable of efficient practice management.     

Retreat from Alma Ata? The WHO's report on Task Shifting to community health workers for AIDS care in poor countries

Abstract

This paper examines the potential of community health worker (CHW) programmes, as proposed by the 2008 World Health Organisation (WHO) document Task Shifting to tackle health worker shortages, to contribute to HIV/AIDS prevention and treatment and various Millennium Development Goals in low-income countries. It examines the WHO proposal through a literature review of factors that have facilitated the success of previous CHW experiences. The WHO has taken account of five key lessons learnt from past CHW programmes (the need for strong management, appropriate selection, suitable training, adequate retention structures and good relationships with other healthcare workers). It has, however, neglected to emphasise the importance of a sixth lesson, the ‘community embeddedness’ of CHWs, found to be of critical importance to the success of past CHW programmes. We have no doubt that the WHO plans will increase the number of workers able to perform medically oriented tasks. However, we argue that without community embeddedness, CHWs will be unable to successfully perform the socially oriented tasks assigned to them by the WHO, such as health education and counselling. We locate the WHO's neglect of community embeddedness within the context of a broader global public health trend away from community-focused primary healthcare towards biomedically focused selective healthcare.     

Has the diffusion of primary care teams in France improved attraction and retention of general practitioners in rural areas?

Many countries, including France, are facing the old and persistent problem of geographical inequalities of their health human resources, in particular general practitioners (GPs). This situation leads, among other things, to underserved areas, which could result in a lower level of primary health care accessibility. Since the mid-2000s in France, several policies were implemented to provide financial as well as other incentives to support the development of multi-professional group practices, Primary Care Teams (PCTs), in order to attract and retain GPs in underserved areas. This study aims to measure the impact of PCTs settlement on the evolution of GP density in rural areas. To this end, we compare the evolution of GP density between rural areas with PCTs and similar rural areas without PCTs, before (2004–2008) and after (2008–2012) the development of PCTs facilities. The results show that PCTs are mainly located in underserved areas and suggest that they could attract and retain GPs there. Those results should be of interest to countries facing relatively similar geographical inequalities issues and that are also experimenting with multi-professional group practices.     

Financial incentives in health: New evidence from India's Janani Suraksha Yojana

This paper studies the health effects of one of the world's largest demand-side financial incentive programmes—India's Janani Suraksha Yojana. Our difference-in-difference estimates exploit heterogeneity in the implementation of the financial incentive programme across districts. We find that cash incentives to women were associated with increased uptake of maternity services but there is no strong evidence that the JSY was associated with a reduction in neonatal or early neonatal mortality. The positive effects on utilisation are larger for less educated and poorer women, and in places where the cash payment was most generous. We also find evidence of unintended consequences. The financial incentive programme was associated with a substitution away from private health providers, an increase in breastfeeding and more pregnancies. These findings demonstrate the potential for financial incentives to have unanticipated effects that may, in the case of fertility, undermine the programme's own objective of reducing mortality.     

A Comparative Assessment of West Virginia's Financial Incentive Programs for Rural Physicians

ABSTRACT: Context: Financial incentive programs are increasingly being used as a strategy to recruit physicians to underserved rural areas. Critical evaluation of state supported programs is often lacking but is necessary to determine their efficacy and to improve outcomes. Purpose: The purpose of this study was to assess 4 service-contingent programs in West Virginia, a state with critical physician shortages. Methods: Survey instruments were developed to evaluate the effectiveness of these programs and to document the practice environments and career paths of obligated allopathic and osteopathic physicians compared with a control group of nonobligated rural practitioners. Data were also collected from physicians who were recipients of multiple incentive programs and from obligated physicians who had defaulted. Findings: Responses from more than 60% of surveyed physicians indicated that the typical respondent was a married white male who was a midcareer Family practice physician. Obligated physicians were more likely than nonobligated physicians to have graduated from a West Virginia medical school and residency program, to be influenced by financial factors in their career decisions, to provide care to uninsured patients, and to work in offices that offered sliding fee scales. Both groups of physicians demonstrated similar retention patterns, reported a high degree of job satisfaction, and expressed a need for more practice management training. Conclusions: Although these financial incentive programs were found to be effective in recruiting primary care physicians to medically underserved areas of the state, the financial support of these programs was found to be too modest, and improved marketing of the programs was indicated.     

村卫生室人员执业现状及待遇保障分析——基于6省18县的调查

目的:分析村卫生室人员执业现状及待遇保障情况。方法:根据经济社会发展水平抽取6省18县(市/区),利用自制调查表调查18县下辖的全部村卫生室。结果:每千农村人口村卫生室人员均数0.7~1.9人;每村卫生室人员均数为1.36~3.24人;部分省村卫生室60岁人员占比超过20%;50%以上村卫生室人员学历为中专且仅有乡村医生执业证书;西部2省村卫生室人员医疗责任险覆盖比例低于11%;除江苏外,其他5省村卫生室人员主要参加新农村养老保险;江苏每村卫生室人员公共卫生和基药补助最高,福建省最低;纳入乡镇卫生院编制管理的村卫生室人员占比低于20%;除江苏外,70%以上村卫生室人员提供24小时服务;村卫生室流出人员超过新进人员。结论及建议:提高村医素质并明确身份;保障村医待遇;鼓励开展研究提出吸引卫生人员到农村执业的更切实可行的建议。