DAKAR, 1 July 2010 (IRIN) - A group of 40 experts convened by the UN World Health Organization (WHO) is finalizing recommendations to help governments attract more health workers to sparsely staffed areas.

Initial findings include: medical graduates with a rural background are more likely to work outside urban areas; internet and rural health worker associations help workers feel less isolated and more satisfied; and the availability of housing and schools can convince people to stay in under-served areas.

"There is no magic solution," Jean-Marc Braichet, WHO's coordinator of health workforce, migration and retention, told IRIN. "No one strategy will work on its own. There is talk of higher salaries [for rural workers], but money is not enough."

He said living conditions played an important role in attracting – and retaining – rural health workers.

Chad

In the region bordering Lake Chad, there are 17 health centres serving half the area's total population of 450,000, according to the 2009 census. Only five centres offer housing for health workers, said Raoul Ngarhounoum, the regional Health Ministry director in the city of Bol, the administrative seat for Lake region.

"We cannot get people to come from [the capital] N'djamena if there is nowhere for them to sleep or for their family to accompany them. There are qualified candidates, just not those who are ready to go to half-functioning health centres. In Berlet [health zone], the director sleeps in the clinic."

Vaccine coverage is poor, health centre supervision is weak and medical staffing is scarce in Bol health district, with only one medical doctor for the entire district, who also happens to be the state's Health Ministry regional director, Ngarhounoum.

In Tataverom, one of Bol's districts, a former school teacher now oversees the clnic. "There was no one else able to read and do the job. Living conditions there are very tough. That is the main reason health workers who are sent there end up leaving," said Ngarhounoum.
Two hundred kilometres northeast of Bol in the regional capital of Kanem region, Mao, health clinic director Younous Yaya Mouli told IRIN the pipes from the well serving the health centre had been broken for two weeks. "We are getting water from a neighbour's reserve."

There is no electricity. The refrigerator storing polio vaccines from a recent vaccination campaign is fuelled by petrol. The centre does not have transportation to reach the 26 villages it serves. "We have no midwife, and our birth attendants have attended one training at the district level," Mouli told IRIN.

Incentives

For a recent WHO publication on health workforce retention in rural areas, researchers asked 1,000 recent nursing graduates from Kenya, South Africa and Thailand what factors could most influence their decision to work in a remote area.

In Kenya and South Africa, respectively, financial incentives made nurses 12 and seven times more likely to work in rural areas. For Thai nurses, improved housing and benefits were more important than a 30-percent salary increase. But the study revealed rural service is an easier sell in Thailand: even without any incentives, 84 percent of Thai nursing graduates would take rural jobs versus 43 percent in Kenya and 36 percent in South Africa.

The best mix of strategies for rural recruitment depends on the type of health workers and their context, said WHO's Braichet. "It is hard to quantify the influence of one incentive over another. [For example], for the young generation, housing is very important because they do not want to feel isolated." He said another way to alleviate isolation would be to install internet services. "These investments are good not only for the health workers, but also the populations they serve."

Other expert group recommendations include: training, such as targeted admission policies to attract students with rural backgrounds; compulsory service requirements in remote areas; financial incentives, and personal and professional support, including equipment, schools, career development and "telehealth" communications to link workers in remote areas to better-served ones.