Dr. Kate Tulenko

By Kate Tulenko. The world currently has a shortage of some 4 million health workers. This shortage is amplified by a complete mismatch between where health workers are stationed and where they are most needed.  The healthier and wealthier a community is, the more health workers it has. The poorer and sicker a community, the fewer health workers it has. The situation is worsening as every year hundreds of thousands of health workers move from poor, rural, and underserved communities to wealthier, metropolitan communities with a surfeit of health workers. This occurs both within countries (a nurse moving from a rural area to the capital city) and between countries (a doctor moving from a developing country to a wealthy country).

Governments and their development partners have struggled to address this problem. Many have tried mandating new graduates to provide a few years of service in underserved areas. These programs have met with variable success depending on the governments’ commitment and ability to enforce the plan. Since the publication of the World Health Organization’s well-thought out and evidence-based guidelines on increasing access to health workers in rural areas, some health systems are implementing mid- and long-term solutions such as recruiting and training health workers in underserved communities.

But governments are under intense pressure to solve the problem now. Some have tried rural retention schemes but many of these have been too expensive to maintain long term or scale up to the entire country. For example, Zambia has a rural retention program for physicians, but the program is funded by an external donor (not sustainable) and the salaries are significantly out of proportion with the salaries of other health workers as well as per capita income in the country. These programs also tend to be more expensive than necessary because ministries of health tend to design them without involving the workers in the rural areas that they want to retain or even workers in metropolitan areas that they want to post to underserved areas. The plans have no foundation in evidence.

There is a solution. Its fancy name is “discrete choice experiment” (DCE). A tool from the field of economics, DCE systematically asks individuals what levels of certain benefits such as housing, vacation, continuing education, improved work environment, and salary would be required for them to accept or remain in a job under given conditions. DCE has been proven in the health sector and other sectors to accurately predict needed incentives and has been proven in follow-up studies to lead to the desired level of retention. The challenge with DCE is that its traditional form has been very complex, requiring PhD-level economists to be flown in, and takes months to conduct and analyze. Recognizing that this isn’t feasible for most health ministries or faith-based health systems in developing countries, IntraHealth International, through its USAID-funded CapacityPlus project, designed a simpler version of the DCE that can be performed by most ministries of health or small organizations.

The process starts with small focus groups of health workers who can brainstorm new benefits that the employer may not have thought of, like internet access, a spousal educational allowance, or low-interest loans to buy a house or car. The focus groups then help define the various levels of benefits that should be tested. This informs the development of the final survey that is given to health workers. The analysis yields a variety of packages and the estimated percent retention they would yield. CapacityPlus has also created free software to compute the long-term costs of implementing the various retention packages to ensure that the chosen package is sustainable. The ministry then has an evidence-based retention package that it can roll out at a national level with confidence that it will succeed. For small health systems that find even this simpler DCE process too daunting, a quick look at the sample menu of retention benefits in our kit followed by focus groups with their workers can help design a more affordable, effective retention package.

It’s particularly important for health systems’ leaders to listen to the voices of all health workers, especially those already in underserved areas, precisely because these leaders have traditionally come from and listened to workers in major metropolitan areas. In addition, the majority of health system leaders are men whereas the majority of health workers are women.  The saying goes, “Those closest to the fire, get most warmed,” and it’s no surprise then that in most developing countries, as well as the US[1], health workers in cities are paid more than health workers in rural areas. No wonder rural health workers move to the cities! So let’s add a little DCE to the mix in the short run. In the long run to solve health worker maldistribution we need to recruit health workers from and train them in underserved communities. And who should you recruit from rural, poor, and other underserved communities? Just ask them!


[1]Medicaid, Medicare, and many private insurers pay more for the same service in metropolitan areas than in rural areas.

Dr. Kate Tulenko is a globally recognized expert in the field of health labor markets and health workforce planning and management. She serves as Senior Director for Health Systems Innovation for IntraHealth International, a global health nonprofit organization that for thirty years has worked to strengthen health workers and the systems that support them in developing countries. She previously coordinated the World Bank’s Africa Health Workforce Program, which conducted research and funded programs to help African countries train and retain health workers. She has served on expert panels for the World Health Organization, the Rockefeller Foundation, the US Agency for International Development, the Global Health Workforce Alliance, and the African Union. She can be followed on Twitter at @ktulenko and online at http://ktulenko.wordpress.com/.

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