Health Professionals’ Education for Practice in Rural and Underserved Areas
5.1 Introduction
CHAPTEr 5
Health Professionals’ Education for Practice in Rural and
and the report of the Task Force on Scaling Up Education and Training of Health Workers. The introduction of the report states:
“Skilled and motivated health workers in sufficient numbers at the right place and at the right time are critical to deliver effective health services and improve outcomes. A shortage of qualified health workers in remote and rural areas impedes access to healthcare services for a significant percentage of the population, slows progress towards attaining the Millennium Development Goals and challenges the aspirations of achieving health for all” (Task Force for Scaling Up Education and Training for Health Workers, 2008).
Four broad categories of recommendations were proposed: educational, regulatory, financial, and personal and professional support Table 5.1.
Table 5.1: Categories of interventions used to improve attraction, recruitment and retention of health workers in remote and rural areas
Categories of Intervention Examples
A Educational interventions Recruit students with a rural background
Health professional schools outside of major cities Clinical rotations in rural areas during studies Curricula that reflect rural health issues
Continuous professional development for rural health workers
B Regulatory interventions Enhanced scope of practice Different types of health workers Compulsory service
Subsidised education for return of service C Financial incentives Appropriate financial incentives
D Professional and personal
support Better living conditions
Safe and supportive working environment Outreach support
Career development programmes Public recognition measures Source: DoH (2011)
with regard to educational strategies, the focus of this chapter, five recommendations were made:
a Get the ’right’ students: 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 practice in rural areas.
b Train students closer to rural communities: 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.
c Bring students to rural communities: Expose undergraduate students from different 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.
d Match curricula with rural health needs: Revise undergraduate and postgraduate curricula to include rural health topics to enhance the competencies of health professionals working in rural areas, and thereby increase their job satisfaction and retention.
e Facilitate professional development: Design continuing education and professional development programmes that meet the needs of rural health workers and are accessible from where they live and work, so as to support their retention.
These recommendations were developed following a comprehensive review of relevant, available evidence related to health workforce attractiveness, recruitment and retention in remote and rural areas. Nonetheless, the review has its limitations as much of the evidence comes from observational, rather than experimental studies; it is possible that confounding variables may have influenced the observed outcomes of the complex interventions studied. The WHO expert group considered that in this field it is equally important to understand whether an intervention works or not (effectiveness), and why it works and how. Context is a key element that can be responsible for different outcomes or results from the same intervention and thus needs to be better captured in the research on these interventions.
In Africa, the regional Office of the wHO published a road Map for scaling up the human resources for health for improved service delivery in the African Region:
2012 – 2025. It identified the following six strategic areas for achieving its objectives:
a Strengthening health workforce leadership and governance capacity.
b Strengthening HRH regulatory capacity.
c Scaling up education and training of health workers.
d Optimising the utilisation, retention and performance of the active health workforce.
e Improving health workforce information and generation of evidence for decision-making.
f Strengthening health workforce dialogue and partnership.
While echoing the global approach of the parent body in taking a broad health systems perspective, the regional office does emphasise the central role of the education and training of health workers, but without a specific emphasis on rural or underserved areas.
It is important to clarify the definitions of ‘rural’, ‘remote’ and ‘underserved’ areas for the purposes of monitoring and funding these interventions. In the USA, the term
‘health professional shortage areas’ (HPSAs) are federally designated as having shortages of primary medical care, dental or mental health providers and may be geographic (a county or service area), demographic (low-income population) or
institutional (health centre or other public facility). Medically underserved areas/
populations are areas or populations designated as having too few primary care providers, high infant mortality, high poverty and/or high elderly population. For the purposes of this chapter, ‘rural and underserved’ areas are defined as areas or sub-districts outside of metropolitan areas where there is a limitation of access to first-contact health services. ‘remote rural’ areas are understood as those with a very low population density, usually at a greater distance from human settlements than ‘rural’ areas.