Bulletin of the World Health Organization

Early implementation of WHO recommendations for the retention of health workers in remote and rural areas

James Buchan a, Ian D Couper b, Viroj Tangcharoensathien c, Khampasong Thepannya d, Wanda Jaskiewicz e, Galina Perfilieva f & Carmen Dolea g

a. Queen Margaret University, Edinburgh, Scotland.
b. Centre for Rural Health, University of Witwatersrand, Johannesburg, South Africa.
c. International Health Policy Programme, Ministry of Health, Bangkok, Thailand.
d. Department of Health Personnel, Ministry of Health, Vientiane, Lao People’s Democratic Republic.
e. IntraHealth International, Chapel Hill, North Carolina, United States of America.
f. Europe Regional Office, World Health Organization, Copenhagen, Denmark.
g. Health Systems Policies and Workforce, World Health Organization, 20 avenue Appia, 1211 Geneva, Switzerland.

Correspondence to Carmen Dolea (e-mail: doleac@who.int).

(Submitted: 10 March 2013 – Revised version received: 31 May 2013 – Accepted: 06 June 2013.)

Bulletin of the World Health Organization 2013;91:834-840. doi: http://dx.doi.org/10.2471/BLT.13.119008


Any shortage of health workers can prevent good access to health services and is a barrier to universal coverage. When such shortages are accompanied by an unequal distribution of the workers, their impact can be even more dramatic.

The maldistribution of health workers between urban and rural or remote areas is a concern in virtually all countries. In Senegal, for example, the Dakar region, which is mostly urban, has more than 60% of the country’s physicians but only 23% of the total population.1 In Canada – where 99.8% of the territory is rural – 24% of the population but only 9.3% of the physicians lived in rural areas in 2006.2 About one half of the world’s population lives in rural and remote areas, but this half is served by only one quarter of the world’s doctors and by less than one third of the world’s nurses.3

Lack of access to health workers in rural and remote areas often leads to relatively high mortality rates in such areas. It also leads to rural residents seeking care at urban health facilities and thus to overcrowding – and increased costs – at urban hospitals. The relatively higher levels of staff in urban areas and facilities may lead to the underutilization of skilled personnel, who may then consider emigration.4

In 2010, the World Health Organization (WHO) addressed the long-standing problem of the maldistribution of health workers. First, it facilitated intergovernmental negotiations that led to the adoption – by all of WHO’s Member States – of a code of practice for the international recruitment of health personnel.5 Second, it established a global task force to examine the adverse effects of the intra-country relocation of health workers – mainly from rural to urban areas – which then developed 16 evidence-based recommendations for the improved retention of health workers in remote and rural areas (Table 1).3 Although no systematic approach to collect in-depth information about the implementation of these recommendations has yet been made, this paper provides broad details of progress across two regions, and more specific details of the lessons learnt in using these recommendations in two countries.

Implementing the recommendations

Adaptation to country context

Lao People's Democratic Republic

Health workers in the Lao People's Democratic Republic are concentrated in cities, although more than 70% of the country’s population lives in rural areas.6 In an attempt to correct this maldistribution, the Laotian health ministry began to develop a strategy for the retention of health workers in those areas. This strategy was built, in part, on the national “2020 Health Personnel Development Strategy” and on a governmental decree that established guidelines for implementing financial incentives for rural civil servants.7 To assess which of WHO’s 16 recommendations would be most effective in the Laotian context, the Ministry of Health – in partnership with CapacityPlus and WHO8 – used a retention survey tool that had been developed from the recommendations9 to conduct a discrete choice experiment.10 The results of surveys involving 970 students who were training to become professional health workers and 483 people who were already health workers, indicated that salary levels became less of an issue when a set of other, highly valued incentives, such as promotion and study opportunities, was offered. The Laotian health ministry subsequently used a costing tool11 to gauge the financial feasibility of implementing the preferred sets of incentives and to assist the relevant policy-makers in their decision-making.

The results of the surveys and costing were used to develop a new, national policy for the recruitment and retention of health workers. This policy – which was announced by the Laotian government in October 2012 – stipulates that all graduates in medicine, nursing, midwifery, pharmacy and dentistry and all postgraduates in family medicine must complete three years of service as a health worker in a rural area before they can receive their licences to practise in their field of study.12 The policy also stipulates the provision of incentives to encourage new health workers both to provide high-quality services while they work in rural areas and to continue working in a rural area after they have completed their three years of compulsory service. The provided incentives include permanent civil service positions, transportation and eligibility for continued education. The first phase of the implementation of the policy began in early 2013 and focused on 400 newly qualified doctors, pharmacists and dentists who were assigned to health centres and district hospitals serving 142 rural districts.

South Africa

WHO policy guidelines for health worker retention were launched at an event hosted by the University of the Witwatersrand’s Centre for Rural Health, in South Africa. At this event, there was a clear call for countries with large rural populations to adapt the global recommendations to their local contexts. The launch event in South Africa, the call for local adaptation and the fact that South Africa faces a severe crisis in its health workforce provided the impetus for a contextualization of WHO guidelines to local – South African – conditions and needs. Thus, in early 2011, a group of national academic and civil society institutions – the University of the Witwatersrand’s Centre for Rural Health, the Rural Doctors Association of Southern Africa, the University of KwaZulu-Natal Centre for Rural Health and the University of Cape Town Primary Health Care Directorate – under the leadership of South Africa’s Rural Health Advocacy Project developed a document that adapted WHO’s recommendations for use in South Africa. The document was distributed for stakeholder review in June 2011 and further inputs were subsequently obtained from Rural Rehabilitation South Africa and the South African Committee of Health Sciences Deans. The “final” contextualization document that was released publicly is a “living document” that is intended to be the basis for continuous discussion and ongoing development.13 Inputs from all categories of health workers in South Africa and other stakeholders are still being sought.

The contextualization document describes WHO guidelines as long-term strategies, illustrates four categories of interventions with specific examples for South Africa, and makes recommendations for the scaling up of these interventions or for adding to them. The recommendations formulated in this document were submitted to South Africa’s national Department of Health, as part of an engagement around the development of a new “human resources for health plan” for South Africa. Many of them were subsequently included in the new plan, which was launched in October 2011.14 As a result of the contextualization document, the plan included a priority area entitled: “Access in rural and remote areas” – as well as seven other priority areas in which issues relating to access to health care in rural areas were also embedded. The partnership being led by the Rural Health Advocacy Project is continuing to engage with the South African Department of Health on the establishment of a taskforce to develop an implementation plan for improving “access in rural and remote areas”. A detailed implementation plan has already been drafted by the partnership. More recently, the partnership has been in discussion with the various groups that have been working on the development of human resource norms and indicators for all levels of the health service in South Africa.

The continued importance of WHO’s recommendations in the South African context was confirmed by a recent consensus statement made by a panel of rural health experts.15 This statement listed the top five challenges for health care in rural South Africa (Table 2) and these challenges were mostly workforce issues like those identified in WHO’s guidelines.

Policy analysis and mutual learning

Asia perspective

The Asia-Pacific Action Alliance on Human Resources for Health took a joint learning approach to assessing WHO’s 16 recommendations. In 2012–2013, the Alliance convened a study to assess policies to improve the retention of health workers in the rural areas of five countries, with reference to WHO recommendations.16 A policy analysis tool was used to map existing and potential retention strategies – from formulation to implementation – and to assess or predict outcomes. The aims were to scale up the policies that worked well and either scale down the other policies or minimize the barriers to their effective implementation. Initially, only existing policies were investigated (Table 3). Although different sets of relevant interventions were applied in the five study countries, the recruitment of students from rural backgrounds, mandatory rural service by new graduates and the use of financial or non-financial incentives were common. There appears to have been little attempt to evaluate the success of any of these interventions. In a systematic review of retention strategies, the interventions that had been evaluated had multiple effects, at different points on a continuum that ran from the attraction of health workers to their recruitment, retention and impact.17 For example, the building of schools in rural areas seems to improve the attraction of students at the schools to rural work but appears to have no impact on long-term retention. In contrast, outreach interventions appear to improve the retention and performance of health workers in rural areas but have no significant effect on recruitment.17 It can be difficult to isolate the impact of any one intervention when several are being implemented at the same time and in the same place. There may be many confounding factors and there may also be a lack of specific “intervention logic” that clarifies the expectations of each intervention’s designers.17,18 Recent theoretical frameworks may help to identify the interplay of the different factors involved by providing a systematic and comprehensive approach for the design, implementation, monitoring, evaluation and review of such interventions.19,20 Such frameworks make use of a systems approach that differentiates between “impact” – for example, in terms of the attraction and retention of health workers in underserved areas – and “inputs”, “outputs” and “outcomes”. They provide a set of indicators to measure progress in implementing various strategies and allow their users not only to determine what does or does not work but also to explore the contextual factors that influence success or failure. The frameworks also help to address “heads-on” challenges – such as the absence of baseline indicators – and the need for a multi-stakeholder approach in the design, implementation and impact evaluation of interventions.

The investigations in five Asian countries involved policy-makers from the beginning. It is hoped that the findings will empower policy-makers to take steps to overcome any identified weaknesses and to scale up the workable strategies. The results of the second phase of these investigations – to be published in late 2013 – should help to provide revised, evidence-based, policy options for improving retention strategies in the five study countries.

Europe perspective

In Europe, WHO recommendations have sparked a sustained effort to document existing, related practices in the region, and to facilitate joint learning through a series of subregional workshops organized by WHO and the Royal Tropical Institute in Amsterdam.21 These workshops have allowed for a detailed mapping of current policies – and an informed exchange on the challenges in implementing them – in 20 countries, notably in the south and east of the region. Initial findings from these countries (Table 4) indicate that the recruitment of health workers to remote and rural areas and their retention in such areas have been promoted by a range of policies covering education, regulation and financial, professional and personal support. However, the success of these systems is often difficult to evaluate. There is a need for situation analysis and impact assessment, which are both identified as important aspects of the successful implementation of WHO guidelines. As the recommended interventions should be “bundled” and can be costly, any mismatch between what is proposed and what may be effective can lead to a substantial waste of resources.


WHO recommendations for the retention of health workers in remote and rural areas have been a useful guide in many countries, particularly for initiating a more structured and focused policy dialogue, strengthening the collection of evidence and supporting policy development. However, more effective mechanisms to share the lessons learnt, to assess impact and to explore the links between the rural availability of health workers and universal health coverage are needed. Such mechanisms should help answer several critical policy questions, including: “How do different types of retention interventions really work?” and “What are the contextual factors that most influence intervention success?” We also need to know how comprehensive situation analysis can be conducted so that policy responses can be aligned with the expectations and needs of health workers, and so that the most effective mix or “bundle”19 of interventions in any given context can be identified.

At a ministerial level meeting held in February 2013, effective distribution of health workers was identified as a key component in achieving universal health coverage.22 Such coverage is also predicated on reforms in health financing. If the central role to be played by equitably distributed health workers in achieving universal health coverage is to be supported, the effects of these finance-related reforms on incentive systems for health workers will also have to be assessed.23,24

Competing interests:

None declared.