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In the United States, rural populations have a lower life expectancy than urban populations and face shortages of health care providers. This report discusses the challenges facing rural health care systems and efforts to expand the rural health care workforce.

The Ethiopian health sector faces a number of challenges related to human resources, including geographical imbalances in the distribution of health workers, problems with job satisfaction, and a high willingness to migrate abroad. To address these challenges with appropriate policies, more empirical evidence is needed. The Ethiopian Health Workers Cohort Study was set up to produce evidence as input to policy design. To generate insights on health workers' career choices, preferences, and job satisfaction, the study followed the same health workers over time. The first wave of the study was conducted in April 2004 and surveyed 219 nursing students and 90 medical students who were in their final year of study. In the second wave of the survey, which took place between May and September 2007, researchers re-interviewed the nurses and the doctors, who had now entered the labor market. This paper reports the descriptive findings of the second wave as well as changes that were identified between the two survey rounds. The report is structured as follows. This chapter provides an overview of the Ethiopian health sector and a brief description of the survey methodology. Chapter two presents data on the health professionals' current activities, including the distribution of job functions across locations, sectors, and facilities. Chapter three summarizes the findings on job characteristics such as salaries and nonmonetary benefits; it also provides information about health professionals' level of satisfaction with job and life of and its evolution over time. Chapter four reports the results regarding health workers' willingness to work in rural areas, including an analysis of the evolution of reservation wages for work in a rural area, obtained from responses to contingent valuation questions. Chapter five focuses on the health worker's likelihood of migrating abroad in the near future, again using specially designed questions. Each chapter after chapter two starts with a summary of the pertinent results.

The incident highlights the poor state of rural health care in India, a system blighted by lack of access to health-care facilities, shortages of doctors and paramedic staff, and the predominance of untrained private practitioners as the first point of care. Indian medical education is geared to train doctors to work only in tertiary care and specialised hospitals, so these areas become the primary professional aspiration of health workers, points out Vikram Patel, professor of international mental health at the London School of Hygiene & Tropical Medicine, UK.

Background The World Health Organization (WHO) and the Government of Kenya alike identify a well-performing health workforce as key to attaining better health. Nevertheless, the motivation and retention of health care workers (HCWs) persist as challenges. This study investigated factors influencing motivation and retention of HCWs at primary health care facilities in three different settings in Kenya - the remote area of Turkana, the relatively accessible region of Machakos, and the disadvantaged informal urban settlement of Kibera in Nairobi. Methods A cross-sectional cluster sample design was used to select 59 health facilities that yielded interviews with 404 health care workers, grouped into 10 different types of service providers. Data were collected in November 2011 using structured questionnaires and a Focus Group Discussion guide. Findings were analyzed using bivariate and multivariate methods of the associations and determinants of health worker motivation and retention. Results The levels of education and gender factors were lowest in Turkana with female HCWs representing only 30% of the workers against a national average of 53%. A smaller proportion of HCWs in Turkana feel that they have adequate training for their jobs. Overall, 13% of the HCWs indicated that they had changed their job in the last 12 months and 20% indicated that they could leave their current job within the next two years. In terms of work environment, inadequate access to electricity, equipment, transport, housing, and the physical state of the health facility were cited as most critical, particularly in Turkana. The working environment is rated as better in private facilities. Adequate training, job security, salary, supervisor support, and manageable workload were identified as critical satisfaction factors. Family health care, salary, and terminal benefits were rated as important compensatory factors. Conclusions There are distinct motivational and retention factors that affect HCWs in the three regions. Findings and policy implications from this study point to a set of recommendations to be implemented at national and county levels. These include gender mainstreaming, development of appropriate retention schemes, competitive compensation packages, strategies for career growth, establishment of a model HRH community, and the conduct of a discrete choice experiment.

To compare the cost-effectiveness of the tuberculosis (TB) programme run by the Bangladesh Rural Advancement Committee (BRAC), which uses community health workers (CHWs), with that of the government TB programme which does not use CHWs. TB control statistics and cost data for July 1996 - June 1997 were collected from both government and BRAC thanas (subdistricts) in rural Bangladesh. To measure the cost per patient cured, total costs were divided by the total number of patients cured. In the BRAC and government areas, respectively, a total of 186 and 185 TB patients were identified over one year, with cure rates among sputum-positive patients of 84% and 82%. However, the cost per patient cured was US$ 64 in the BRAC area compared to US$ 96 in the government area. The government programme was 50% more expensive for similar outcomes. Although both the BRAC and government TB control programmes appeared to achieve satisfactory cure rates using DOTS (a five-point strategy), the involvement of CHWs was found to be more cost-effective in rural Bangladesh. With the same budget, the BRAC programme could cure three TB patients for every two in the government programme.

Background Sierra Leone has faced a shortage and maldistribution of staff in its post-conflict period. This long-standing challenge is now exacerbated by the systemic shock and damage wrought by Ebola. This study aimed to investigate the importance of different motivation factors in rural areas in Sierra Leone and thus to contribute to better decisions on financial and non-financial incentive packages, here and in similar contexts. Methods This article is based on participatory life histories, conducted in 2013 with 23 health workers (doctors, nurses, midwives and Community Health Officers) in four regions of Sierra Leone who had worked in the sector since 2000. Although the interviews covered a wide range of themes, here we present findings on motivating and demotivating factors for staff, especially those in rural areas, based on thematic analysis of transcripts. Results Rural health workers face particular challenges, some of which stem from the difficult terrain, which add to common disadvantages of rural living (poor social amenities, etc.). Poor working conditions, emotional and financial costs of separation from families, limited access to training, longer working hours (due to staff shortages) and the inability to earn from other sources make working in rural areas less attractive. Moreover, rules on rotation which should protect staff from being left too long in rural areas are not reported to be respected. By contrast, poor management had more resonance in urban areas, with reports of poor delegation, favouritism and a lack of autonomy for staff. Tensions within the team over unclear roles and absenteeism are also significant demotivating factors in general. Conclusions This study provides important policy-focused insights into motivation of health workers and can contribute towards building a resilient and responsive health system, incorporating the priorities and needs of health workers. Their voices and experiences should be taken into account as the post-Ebola landscape is shaped.

Background Bangladesh is a highly populous country with three-quarters rural population. Pressing national shortages in health professionals has resulted in high vacancy rates in rural areas. These are compounded by excessive absenteeism and low retention among nurses and doctors posted to rural locations. This study attempts to ascertain reasons for providers’ reluctance to work in rural and remote areas and to identify ways in which these barriers to appropriate staffing might be resolved. Methods This is a qualitative study based on in-depth interviews with healthcare providers ( n  = 15) and facility managers ( n  = 4) posted in rural areas, and key informant interviews with health policymakers at the national level (n = 2). Interview guides were written in English and translated and administered in Bengali. The collected data were re-translated and analyzed in English. Braun and Clarke’s thematic analysis approach (data familiarization, coding, identifying and reviewing themes, and producing a final report) was used. Results Participants reported poor living conditions in rural areas (e.g., poor housing facilities and unsafe drinking water); overwhelming workloads with poor safety and insufficient equipment; and a lack of opportunities for career development, and skill enhancement. They reported insufficient wages and inadequate opportunities for private practice in rural areas. Managers described their lack of sufficient authority to undertake disciplinary measures for absenteeism. They also pointed at the lack of fairness in promotion practices of the providers. Policymakers acknowledged unavailability or insufficient allowances for rural postings. There is also a lack of national policy on rural retention. Conclusions The findings revealed a complex interplay of factors influencing doctors’ and nurses’ availability in rural and remote public health facilities from the perspective of different players in the healthcare delivery system of Bangladesh. In addition, the study generated several possibilities for improvement, including increased allowances and incentives for rural posting; a transparent and fair promotion system for serving in rural areas; enhanced authority of the local managers for reducing worker absenteeism; and improved national policies on rural retention.

Introduction The aim of this study was to identify whether policies in different stages of medical system reform had been effective in decreasing inequalities and increasing the density of health workers in rural areas in China between 1985 and 2011. Methods With data from China Health Statistics Yearbooks from 2004 to 2012, we measured the Gini coefficient and the Theil L index across the urban and rural areas from 1985 to 2011 to investigate changes in inequalities in the distributions of health workers, doctors, and nurses by states, regions, and urban-rural stratum and account for the sources of inequalities. Results We found that the overall inequalities in the distribution of health workers decreased to the lowest in 2000, then increased gently until 2011. Nurses were the most unequally distributed between urban-rural districts among health workers. Most of the overall inequalities in the distribution of health workers across regions were due to inequalities within the rural-urban stratum. Discussions and conclusions Different policies and interventions in different stages would result in important changes in inequality in the distribution of the health workforce. It was also influenced by other system reforms, like the urbanization, education, and employment reforms in China. The results are useful for the Chinese government to decide how to narrow the gap of the health workforce and meet its citizens’ health needs to the maximum extent.

The scarcity of rural doctors has undermined the ability of health systems in low and middle-income countries like India to provide quality services to rural populations. This study examines job preferences of doctors and nurses to inform what works in terms of rural recruitment strategies. Job acceptance of different strategies was compared to identify policy options for increasing the availability of clinical providers in rural areas. In 2010 a Discrete Choice Experiment was conducted in India. The study sample included final year medical and nursing students, and in-service doctors and nurses serving at Primary Health Centers. Eight job attributes were identified and a D-efficient fractional factorial design was used to construct pairs of job choices. Respondent acceptance of job choices was analyzed using multi-level logistic regression. Location mattered; jobs in areas offering urban amenities had a high likelihood of being accepted. Higher salary had small effect on doctor, but large effect on nurse, acceptance of rural jobs. At five times current salary levels, 13% (31%) of medical students (doctors) were willing to accept rural jobs. At half this level, 61% (52%) of nursing students (nurses) accepted a rural job. The strategy of reserving seats for specialist training in exchange for rural service had a large effect on job acceptance among doctors, nurses and nursing students. For doctors and nurses, properly staffed and equipped health facilities, and housing had small effects on job acceptance. Rural upbringing was not associated with rural job acceptance. Incentivizing doctors for rural service is expensive. A broader strategy of substantial salary increases with improved living, working environment, and education incentives is necessary. For both doctors and nurses, the usual strategies of moderate salary increases, good facility infrastructure, and housing will not be effective. Non-physician clinicians like nurse-practitioners offer an affordable alternative for delivering rural health care.

Background: Estimates of the relative contributions of physicians, physician assistants (PAs), and nurse practitioners (NPs) toward rural primary care are needed to inform workforce planning activities aimed at reducing rural primary shortages. Objectives: For each provider group, this study quantifies the average weekly number of outpatient primary care visits and the types of services provided within and beyond the outpatient setting. Methods: A randomly drawn sample of 788 physicians, 601 PAs, and 918 NPs with rural addresses in 13 US states responded to a mailed questionnaire that measured reported weekly outpatient visits and scope of services provided within and beyond the outpatient setting. Analysis of variance and χ2 testing were used to test for bivariate associations. Multivariate regression was used to model average weekly outpatient volume adjusting for provider sociodemographics and geographical location. Results: Compared with physicians, average weekly outpatient visit quantity was 8% lower for PAs and 25% lower for NPs (P<0.001). After multivariate adjustment, this gap became negligible for PAs (P=0.56) and decreased to 10% for NPs (P<0.001). Compared with PAs and NPs, primary care physicians were more likely to provide services beyond the outpatient setting, including hospital care, emergency care, childbirth attending deliveries, and afterhours call coverage (all P<0.001). Conclusions: Although our findings suggest that a greater reliance on PAs and NPs in rural primary settings would have a minor impact on outpatient practice volume, this shift might reduce the availability of services that have more often been traditionally provided by rural primary care physicians beyond the outpatient clinic setting.