The World Health Organization has released the first global recommendations for improving the retention of health workers in remote and rural areas.

You might think from the way that we often discuss this issue that it is a peculiarly Australian problem, and one that simply requires us to pay rural doctors more. Wrong on both counts.

Globally, about one half of the population lives in rural areas, but less than 38 per cent of the nurses and less than 25 per cent of the physicians work there.

After a year-long consultative effort, the WHO document proposes 16 recommendations on how to improve the recruitment and retention of health workers in underserved areas.  You can see what they are at the bottom of this post (only one of the recommendations relates to financial incentives).

Thanks to Croakey contributor Kim Webber, CEO of Rural Health Workforce Australia, for filing this report from Johannesburg where she has been attending a conference marking the document’s launch. She was a member of the expert panel that advised WHO on the policy guidelines.

Kim Webber’s Johannesburg diary


Fascinating to hear in South Africa of an organization called “Africa Health Placements”.  Like Rural Workforce Agencies in Australia, AHP focuses on recruiting and supporting health workers into their respective areas of interest.

The CEO of AHP discussed their strategies to recruit health workers from Britain, the United States and Australia, just as RWAs are trying to do for Australia’s rural communities.  South Africa has so streamlined and prioritized the assessment processes that they can now arrange for those doctors to commence within two months of contact.  This contrasts to Australia where the processes can take years.

Also amazing to learn of the difficulties that AHP has in mobilizing health workers from the city into rural areas, hence their focus on overseas recruitment. This is the challenge of our times for both of our countries and something we really need to focus on. As the delegate from the Ministry of Health in South Africa said: “We can’t recruit health workers from the trees – they have to come from somewhere and there just aren’t enough to go around.”


New types of health workers has been a hot topic for everyone, particularly the African countries.  Lack of doctors in rural and remote areas has led to a number of new ‘mid-level workers’ being trained and employed. They include nurse anaesthetists in Botswana and clinical associates in South Africa.

Debates covered the potential for dismantling traditional medicine and leading to the diminishing of medicine as a prestigious career. While these fears were acknowledged, there was a feeling that these new professions were necessary to facilitate access to health care for rural and remote people.

This is interesting given Australia is progressing physician assistants and we are clearly not alone in this.

One of the best presentations to bring it all together was from a Thai doctor who talked about why he had worked in rural Thailand (1,000km from Bangkok) for almost 20 years. Explaining why he was happy to remain in a rural area, he said he worked with not only his brain, but with his heart and soul. He discussed the acknowledgement and recognition that he gets from his community and his country (long-service medals for rural doctors are presented by the Thai President no less!) as a key motivator for him.  As he explained, working with heart and soul brings happiness. What a great way to end the conference. In the end this is what we want, committed, happy health workers in rural and remote areas.


The report’s recommendations


1. Use targeted admission policies to enrol students with a rural background in education programmes for various health disciplines, in order to increase the likelihood of graduates choosing to practise in rural areas.

2. Locate health professional schools, campuses and family medicine residency programmes outside of capitals and other major cities as graduates of these schools and programmes are more likely to work in rural areas.

3. Expose undergraduate students of various health disciplines to rural community experiences and clinical rotations as these can have a positive influence on attracting and recruiting health workers to rural areas.

4. Revise undergraduate and postgraduate curricula to include rural health topics so as to enhance the competencies of health professionals working in rural areas, and thereby increase their job satisfaction and retention.

5. Design continuing education and professional development programmes that meet the needs of rural health workers and that are accessible from where they live and work, so as to support their retention.


1. Introduce and regulate enhanced scopes of practice in rural and remote areas to increase the potential for job satisfaction, thereby assisting recruitment and retention.

2. Introduce different types of health workers with appropriate training and regulation for rural practice in order to increase the number of health workers practising in rural and remote areas.

3. Ensure compulsory service requirements in rural and remote areas are accompanied with appropriate support and incentives so as to increase recruitment and subsequent retention of health professionals in these areas.

4. Provide scholarships, bursaries or other education subsidies with enforceable agreements of return of service in rural or remote areas to increase recruitment of health workers in these areas.


1. Use a combination of fiscally sustainable financial incentives, such as hardship allowances, grants for housing, free transportation, paid vacations, etc., sufficient enough to outweigh the opportunity costs associated with working in rural areas, as perceived by health workers, to improve rural retention.


1. Improve living conditions for health workers and their families and invest in infrastructure and services (sanitation, electricity, telecommunications, schools, etc.), as these factors have a significant influence on a health worker’s decision to locate to and remain in rural areas.

2. Provide a good and safe working environment, including appropriate equipment and supplies, supportive supervision and mentoring, in order to make these posts professionally attractive and thereby increase the recruitment and retention of health workers in remote and rural areas.

3. Identify and implement appropriate outreach activities to facilitate cooperation between health workers from better served areas and those in underserved areas, and, where feasible, use telehealth to provide additional support to health workers in remote and rural areas.

4. Develop and support career development programmes and provide senior posts in rural areas so that health workers can move up the career path as a result of experience, education and training, without necessarily leaving rural areas.

5. Support the development of professional networks, rural health professional associations,  rural health journals, etc., in order to improve the morale and status of rural providers and reduce feelings of professional isolation.

6. Adopt public recognition measures such as rural health days, awards and titles at local, national and international levels to lift the profile of working in rural areas as these create the conditions to improve intrinsic motivation and thereby contribute to the retention of rural health workers.

Kim Webber, reporting from South Africa
Kim Webber, reporting from South Africa
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